What resources are available for privately insured patients who receive surprise balance bills? | KFF

For patients with private insurance, surprise medical bills can arise from having to pay a high deductible or from balance billing.” Typically, health plans negotiate payments to network providers. Out-of-network providers can bill privately insured patients directly for the difference between the typical in-network health plan payment and the full charge, also known as balance bills.In such cases, patients may be responsible for the balance bill in addition of any deductible, co-insurance or co-payment of the health plan.

The No Surprises Act bans many of these balance bills starting in 2022. Patients with private insurance (including those with employer-based coverage, nongroup plans, and settlement plans) are protected from certain bills surprise balance Surprise balance billing protections require private health plans to cover out-of-network claims and apply in-network cost sharing (deductibles, copayments) for certain covered benefits. The law prohibits certain providers, hospitals and air ambulances from billing patients the surprise balance for out-of-network care unless the patient agrees in advance.

The new protections require plans and providers to remove patients from many of the most common payment disputes. Although patients may still receive balance bills, even due to plan or provider billing errors, the bill is not covered under the new law (eg, ground ambulance rides, non- covered, out-of-network patient consent). care costs), or the health plan denies the claim entirely because it is not covered by the plan.

The patient can get balanced bills, for example, if the patient’s plan incorrectly processes a claim or applies an out-of-network cost-sharing amount when NSA prohibits it. A patient could be charged more than they should be, for example, if the plan doesn’t recognize that a claim is subject to the No Surprises Act or because of a billing oversight. Patients can appeal these errors through the internal complaints and appeals procedure. Under federal law, a patient has the right to appeal a health plan denial (called an adverse benefit determination, or ABD). ABDs also include plan decisions to apply the incorrect cost-sharing amount. Once the adverse benefit determination is made, the health plan must give the patient a minimum of 180 days to file an internal appeal. For post-service claims, the plan must complete the internal appeal no later than 60 days after it is filed. If the plan maintains its denial, the patient has a new right under the NSA to request an independent external appeal of NSA compliance issues. Federal regulations provide several examples of when NSA-related decisions may be reviewed by an outside reviewer, including a decision on whether a specific claim involves an NSA-covered item or service as a surprise bill.

For patients who receive a surprise bill when they shouldn’t, what comes next can be trickier. To correct the situation, patients should first acknowledge that the plans’ decision was incorrect and that the provider’s bill is subject to the No Surprises Act. The KFF survey finds that the vast majority of Americans (78%) know little or nothing about the new consumer protection law, so the effectiveness of consumer self-advocacy could be limited if problems arise . Under current law, any health plan ABD must include contact information for state consumer assistance programs (CAPs) and advise that these programs (in states where they exist) can help people file an appeal ¬∑lation Consumers could contact the CAPs to get an assessment of whether the bill they received is valid. Also, as part of the No Surprises Act, the Centers for Medicare and Medicaid Services (CMS) has established resources for patients to request a review of their medical bills (via this website: https: //www.cms.gov/medical-bill). -rights/help/submit-a-complaint or by calling the No Surprises Helpline at 1-800-985-3059, available 24 hours a day and on holidays). This no-fault-door complaint system is available to consumers who are concerned that their plan has denied or improperly covered a surprise medical bill.

In the meantime, though, if a plan denies or incorrectly covers a surprise bill and the patient doesn’t acknowledge the mistake so they can appeal or seek a state or federal review, the patient could be stuck with the bill.

Even if patients appeal, there is no federal rule that prevents providers from trying to collect the outstanding bill. For incorrect bills, if the patient appeals, the out-of-network provider could bill the patient for the full charge while the appeal is pending. Patients who cannot pay the outstanding bill may be referred to collection agencies. Although the Consumer Financial Protection Bureau (CFPB) has outlined additional guidelines that restrict the coercive practices of collection agencies. The KFF survey found that 41% of adults have medical debt under a broader definition, which includes medical debt from credit cards or family members. KFF analysis of a census survey suggests that Americans may owe at least $220 billion in medical debt. People with medical debt report cutting back on food, clothing and other household items, spending their savings to pay medical bills, borrowing money from friends or family, or taking on additional debt. Medical debt can make it difficult for patients to get loans for everyday living, such as housing or cars.

Later, if the patient prevails on appeal, the health plan would have to process the claim again, this time following the rules of the No Surprises Act, and the out-of-network provider would have to reimburse the patient any amount charged in excess of the applicable in-network cost sharing amount.

Under the Affordable Care Act and the No Surprises Act, federal agencies can impose penalties on health plans and providers for improperly billing patients.. Plans that process claims incorrectly can be charged up to $100 per day per affected beneficiary under federal law. State regulators may have additional authority and enforcement tools they can use to address billing issues. For the provider, the penalty for incorrect billing is up to $10,000 per violation. That is, if a supplier sends 200 incorrect invoices, the supplier could be penalized $2 million. But for those penalties to occur, the patient would have to file a complaint with federal regulators, and the regulators would have to investigate and enforce.

As of October 2023, about 11,000 patient complaints have been filed through the federal feedback portal. The federal government has said 248 complaints involved a violation and resulted in $3 million in monetary relief paid to consumers or providers. At this time, it is unclear whether the federal government has issued penalties to providers or health plans for improper billing practices.


Most patients are unaware of the new surprise billing protections and are likely unaware of the resources available to seek redress for incorrect medical bills. It is advisable to ask about the cost in advance, when possible. Also, when patients receive a large and unexpected bill, a good first step is to call the health plan. New federal resources allow patients to file complaints and get a response from the federal government. The federal process does not provide a determination or help the consumer fight a bill with the payer. Patients may have little recourse, however, if their plan doesn’t cover certain items or services, or if their surprise balance bill isn’t covered by federal law.

Plans and providers can now arbitrate disagreements about payments for out-of-network care through No Surprises Act independent dispute resolution. Most payment determinations through the arbitration process have been in favor of price-seeking suppliers. However, the majority of lawsuits against the No Surprises Act are also being filed by providers. The federal government recently proposed several changes aimed at making the IDR process more efficient and increasing early communication between the parties. Amid legal disputes over the dispute resolution process for payment rates, patients should be held harmless by surprise, out-of-network balance bills.

Patients are not supposed to receive surprise balance bills unless there is an error or the surprise bill is not protected. In these situations, patients have some resources, although they are only useful if people know about them.

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