The No Surprises Act fights against unexpected medical bills, whether they occur in emergencies or non-emergencies, from healthcare providers who work outside a patient’s insurance network but inside a facility covered by that network. 

The No Surprises Act mainly focuses on helping people with insurance, but it also provides some protections for those without insurance. For example, it makes sure that individuals who don’t have insurance (or pay for their healthcare themselves) get a clear estimate of how much their medical services will cost. 

It also creates a system for people without insurance (who pay for their care on their own) to figure out how much they should pay to a healthcare provider or facility in specific situations. 

Unfortunately, the law’s full rollout has been hindered by legal wrangling over how providers should be compensated for their services. 

What Does the No Surprises Act Not Cover? 

• The Act protects patients from out-of-network bills but not from surprise bills by in-network providers. 
• Ground ambulance services are not covered. 

• The Good Faith Estimate is a useful tool, but it’s not a parachute for emergency situations. 
• It’s a good idea to think twice before signing the so-called Surprise Billing Protection form if you have insurance. It might do more harm than good. 

As reported by patients who’ve utilized the No Surprises Act, it has generally produced positive outcomes. However, there’s still a requirement for a more user-friendly system. 

The No Surprises Act is an essential step forward. It leaves room for improvement, and it does not serve as the ultimate solution to the financial toxicity of our system, but it offers much-needed protection. It’s vital to understand its ins and outs, so we can navigate our healthcare with confidence.  

Additional Information:  

Centers for Medicare & Medicaid Services  

Department of Labor  

Statistic about percent of ambulance rides that are out of network 

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[00:00:25] Allie: As we’ve previously discussed on The Hidden Costs of Health, surprise medical bills have burdened American patients for far too long. These unexpected and exorbitant bills can be nothing short of distressing and frustrating, and I’m sure many of you listening can relate to the anxiety they bring. I know I’ve had my fair share of these experiences.  

[00:00:48] A glimmer of hope recently appeared in 2020 with the passing of The No Surprises Act, a piece of national legislation aimed at protecting patients from surprise bills, which went into effect in January of 2022.  

[00:01:01] At first glance it may seem like the answer we’ve all been waiting for, a shield against the financial turmoil that often accompanies unexpected medical expenses. Sounds great, right? 

[00:01:15] Earlier this year, I was faced with a surprise bill that I expected to be fully covered by insurance. When I was hit with over $7,000 of expenses after insurance, I wasn’t quite sure what to do or where to start. It happened to be when I was in the process of researching and preparing for this show. So, luckily, I knew not to pay it right away. After hours and hours of negotiating and refuting with my insurance company and getting virtually nowhere, I looked into other options.  

[00:01:47] I had heard of The No Surprises Act and decided to give their hotline a call. Unfortunately for me, The No Surprises Act didn’t apply to my situation. Which was, well… a surprise in itself. While there are some safeguards to protect patients, they fell disappointingly short of my expectations.  

[00:02:09] So, what does The No Surprises Act actually cover? And who does this legislation actually help? 

[00:02:17] Hello and welcome to The Hidden Costs of Health. In this show, we’re exploring the burden of medical expenses in this country and how a health event can quickly spiral into financial toxicity. 

[00:02:30] I’m Allie Sandler, a producer for Empowered Us.  

[00:02:34] [Music Ends] 

[00:02:37] The No Surprises Act was introduced as a solution to protect patients from unexpected and burdensome medical bills. But it’s important to be aware of the surprises and limitations associated with this legislation.  

[00:02:52] According to The No Surprises Act website, this legislation restricts surprise billing for insurance-holding patients who get emergency and non-emergency care from out of network providers at in-network facilities, requires good faith estimates of medical items or services for uninsured individuals, establishes a dispute resolution process for uninsured individuals to determine payment amounts due to a provider or facility under certain circumstances.  

[00:03:23] If I had read into these rules closer, I would’ve realized that I was ineligible for coverage through The No Surprises Act. What was most deceptive to me was the specific definition of surprise bill.  

[00:03:36] To me and many others, a surprise medical bill is a financial jolt, an invoice that far exceeds the initial quote or expectation. But within the confines of The No Surprises Act, a surprise medical bill is defined as an unexpected bill from an out of network provider or at an out of network facility. 

[00:03:58] So, [Music] long story short, The No Surprises Act aims to prevent surprise bills, but it may not cover all scenarios. Patients still may find themselves facing unexpected charges, with the legislation predominantly focused on instances where patients stumble into the realm of out of network care, unknowingly.  

[00:04:19] For those without insurance, or those who opt to pay for their care independently, the act mandates that they receive a good faith estimate before their treatment. This provision aims to provide transparency in the healthcare landscape often marked by a lack of clarity.  

[00:04:38] Now, as a consumer, I’m able to understand the basics of The No Surprises Act, but I wanted to get a stronger understanding of all of the different aspects and protections of this bill. 

[00:04:50] Dane: My name is Dane Christiansen. I’m the managing partner of The Health and Medicine Council, which is an advocacy and government relations firm on Capitol Hill in Washington, D.C.  

[00:05:01] [Music Ends] 

[00:05:02] Allie: Dane, can you tell me a little bit more about The No Surprises Act from your perspective?  

[00:05:07] Dane: The No Surprises Act was passed in 2020, which is the 116th Congress. This was something that was important to the patient community, even though the debate nowadays is more focused on providers and insurers. 

[00:05:21] And the issue at that time was, if you were particularly a rare disease patient, you’d be hit with surprise medical bills, because when you needed care, particularly emergency care, you might not know what is in-network, what is out of network, where should I go, and you’re having an emergency. 

[00:05:37] This was people who were experiencing these problems firsthand, and them saying, this is, seems unfair to me, or this does not make sense, telling that to their elected officials on Capitol Hill, and them trying to respond through their mechanisms and the Federal Health Service to come up with a way to, to deal with this in an appropriate fashion and have a policy solution. This case, by passing a law. 

[00:06:02] Allie: What prompted The No Surprises Act to be enacted in the first place?  

[00:06:06] Dane: Congress has been trying to tackle this issue of out-of-pocket costs for some time, and we’ve seen the debate manifest itself in different ways. So, they needed to find where they had common ground. Where there were things that everyone agreed needed to be changed or regulated. At the time in 2020, when the bill passed, you had a Republican controlled Senate, a Democratic controlled house. You probably had very progressive proposals on out-of-pocket costs. You had very conservative proposals on out-of-pocket costs. 

[00:06:35] The middle ground and where consensus emerged was on The No Surprises Act. That didn’t move forward because of one party or one politician. It moved forward with both parties and both chambers because folks had heard from their constituents, knew this was a problem, and in this broader scheme of how do we make good health policy and lower out-of-pocket costs, they said, what we can get done now in this year is regulating and fixing this issue of surprise medical billing. 

[00:07:03] Allie: Is this act more helpful for people who are insured or for those who are uninsured?  

[00:07:08] Dane: Healthcare is very complex and increasingly personalized, but I would believe on its face in the spirit of the law, this is more for people who are insured. Because if you are not insured, or if you have something like Part A benefits for Medicare, there’s going to be a cohesive national coverage level for you. The No Surprises Act is actually largely regulated by the Department of Labor. 

[00:07:32] The issue that would come up is that you have an amount that you’re expecting to pay. You say, I have a health plan, it says this is my out-of-pocket maximum. It says I do this much when I go to the hospital, I pay this much when I see a doctor. And the problem was, if you went out of network, and you might not even know that you went out of network, now you’re getting hit with a different, much larger amount. 

[00:07:54] There was a concern that there was an incentive to get people into those situations where they might be paying more, or they could be abused. So once again, guardrails to make sure that doesn’t happen. And primarily, the goal was to make sure that the patient ends up paying what they believe they should be paying when they get this type of care and that the, the costs are not borne by them, particularly if they have an emergency situation or some type of exigent circumstance. 

[00:08:19] Allie: Does this bill help regulation on the state level or only on the federal level?  

[00:08:24] Dane: A state can have its own rules, and there’s often a patchwork of coverage depending on where you are. Certain states are stronger in some areas, other states are stronger in different areas, and it creates this kind of, um, inconsistency in what your coverage is. 

[00:08:39] The federal government really steps in to ensure there’s a, there’s a floor or a ceiling in certain situations. So, a state can have more robust protections than what is allowed in The No Surprises Act. They can have additional regulations, they can have further protections for patients. They could not have less. 

[00:08:57] When the government comes in and says, nationally, this is going to be the standard. That is the standard, you can go beyond that standard, but you could not go below it. So, the state can operate anywhere that the government hasn’t made it clear what’s going to happen, or they can go beyond what’s been stated, but they couldn’t say, we’re ignoring this, we’re going to have our own state thing that we do instead.  

[00:09:18] Allie: In my research, I found that a lot of this bill has been implemented, but there are still portions that are being rolled out. Why are there delays on achieving the full scope of The No Surprises Act?  

[00:09:29] Dane: So, what happened after The No Surprises Act was passed in 2020, and they said we’re not going to shift this burden onto patients, they now had a dynamic between insurance providers and the doctors. The doctor has still delivered you care in an emergency situation. They need to be compensated, even if the patient isn’t the one paying the tab. 

[00:09:48] So, the discussion between, well, geez, how much are they getting paid now? How does that work? When does it happen? These types of implementation questions have now shifted to the court due to a number of legal challenges. So, this has delayed final implementation of The No Surprises Act. 

[00:10:05] Allie: Are there any other takeaways from this bill that we should touch on?  

[00:10:08] Dane: If there’s one thing that The No Surprises Act encapsulates, it’s that personal advocacy and sharing your story works. It makes an impact. Members of Congress know that you are a, you have a pure self-interest, you are a neutral arbitrator on your own health care. They know, they hear from insurance companies, they hear from drug companies, they hear from provider groups. 

[00:10:28] But what is most important to your elected officials is how is the system working for you as a patient and as their constituent? Don’t get disheartened, don’t get jaded. You might not agree with the politics of whoever is your senator or representative, but you should have every expectation that if you reach out to their office, you ask for help, whether it’s on something like a medical bill or to advocate for something like The No Surprises Act, they are going to figure out a way to respond to you positively, and even raising awareness of the issue allows them to make policy decisions with your input. 

[00:11:01] Allie: The No Surprises Act shows the power of patient advocacy on the national level. While it has its strengths and weaknesses, there’s no denying that this bill has the capacity to make huge impacts on the way the government interacts with the medical billing system. 

[00:11:16] [Music] 

[00:11:18] I thought it would be a good idea to give you a rundown of what The No Surprises Act encapsulates for patients at the current moment.  

[00:11:25] First off, if you use insurance, The No Surprises Act protects you from out of network bills from emergency room visits and non-emergency room care that’s out of network at an in-network hospital.  

[00:11:38] For example, if you’re being treated at a hospital that’s covered by your insurance, but the attending physician is out of network and they don’t let you know ahead of time with a good faith estimate, you are covered by this bill.  

[00:11:52] When I received a surprise bill, this was the part of The No Surprises Act that confused me the most. The language used makes it sound like in-network, surprise bills are covered, which they are not.  

[00:12:05] Air ambulance services are also protected, however ground ambulances are not, as roughly 85% of all emergency ambulance rides are out of network.  

[00:12:18] If you don’t use insurance, providers must give you a good faith estimate of how much your care will cost at least three days in advance, or if you ask for one. You may be able to dispute your bill if it’s at least $400 more than the estimate. However, The No Surprises Act does not require this, if you’re being treated for emergency care.  

[00:12:40] [Music Ends] 

[00:12:41] Let’s talk about the good faith estimate for a moment. When given this estimate a provider must give you a surprise billing protection form with the projected costs. If you’re insured and you sign it, you no longer have the protections from the surprise billing law. And that means now you’re financially obligated to pay the out of network provider whatever they want to charge you based off of what’s listed on the estimate. Surprise billing protection form is a pretty misleading name if you ask me. This does not apply to emergency situations, which means you will be covered by The No Surprises Act if an out of network provider treats you.  

[00:13:21] So, this is just from the patient’s point of view. For providers and insurance issuers, the provisions are different and resources are listed on The No Surprises Act website. If you want to read about all of your rights and the ins and outs of The No Surprises Act, we’ll have their site linked in the show notes.  

[00:13:39] Now, it’s clear this bill has a lot of pros and cons, but the impact of protections around surprise billing is quite significant.  

[00:13:47] [Music] 

[00:13:48] I had a chance to speak with Nicki Pogue, and advocate for The No Surprises Act, about her surprise billing experience.  

[00:13:57] [Music Ends] 

[00:13:57] Nicki: About five years ago, I was doing a high altitude relay up in, uh, Washington State near Mount Rainier. And I came home feeling pretty lousy, went to my doctor. She prescribed some antibiotics and then antihistamine. And I woke up from taking a nap after being completely wiped out and I just had all kinds of like bizarre symptoms like difficulty breathing and dizziness and weakness and like my extremities were tingling. I had ringing in my ears. And my pulse was like racing at about 120 beats per minute just sitting. 

[00:14:30] I called my downstairs neighbor and I said, I need to get to the hospital, and off we went and we went to what logically anybody would suspect is a good idea is going to your closest hospital and nobody really has time to start looking through the paperwork to see what’s in-network and it turned out that, the hospital I went to was out of network and I was slapped with a tremendous $13,732 bill for five hours in the hospital, and after insurance. 

[00:14:58] And when I got this bill, I thought, it’s insurance. I have insurance. I have insurance. Not a problem. They paid $3,000 of that. So, I was left with a balance due of $10,000, which I thought just was not humanly possible. Why do I pay private insurance if I’m being held responsible for that grand total, and it turns out it’s because the hospital was out of network. 

[00:15:18] Allie: So, you received this large and unexpected bill. What do you do next?  

[00:15:23] Nicki: My first thought was that, oh, we’ll figure out how to make this go away. This must have been a billing error. And then when the follow up bills started coming, I contacted my insurance company, and I did an appeal and I wrote this long letter for them and they rejected the appeal. 

[00:15:37] And during that time, I keep getting bills from the hospital saying, we’re about to send this out for collections. And I had visions of my credit being ruined for something that really was a battle between my insurance company and this hospital. And over the course of the next five months, I reached out to health advocates, consulted an attorney, who helped me get my appeal together. I researched my state and federal legislation options. 

[00:16:03] I also got very intimately familiar with hospital charge masters, which is the giant Excel spreadsheet document that itemizes, inscrutably, but it itemizes the cost of everything from a syringe to a mask to an Advil to a Band Aid to a level 5 emergency room, and I compared notes across different hospitals to see how much things cost, and I realized that I was being charged basically two to three times what other hospitals in San Francisco were charging. 

[00:16:32] I compared notes with a lot of other patients, there were a lot of other patients who were being billed outrageously by the same hospital. And it sort of armed me with a little bit more resilience to try to go after them. And I amassed about an inch and a half of paperwork, all while getting these past due notices and threats to having my account sent to collections. So, here I was stuck in the middle between a hospital that was charging unreasonably high out of network fees, an insurance company that was only going to pay the Medicare rate, which is a fraction of what my bill actually was. 

[00:17:01] And I had the time, and I had the resources, and I had the connections to try to figure all this out. Most families don’t. Most families get a letter like that, and they think, alright, well, there goes the college tuition. We’ll just write a check, and we’ll get this taken care of. And it made me feel a lot of empathy for people who wouldn’t even know the first thing to do to try to fight something like this. 

[00:17:23] Allie: Did any of the hospital staff ever notify you of the fact that you were out of network for your treatment?  

[00:17:29] Nicki: No, we pulled up to the ER and I was, um, making my way to the desk to check in and all of that. They took my insurance card, um, while getting me a wheelchair, because I was having trouble standing. But no one ever said a word. There was never any disclosure that private insurance was off the table and that it was largely because it’s a public hospital, largely to service people who are uninsured. 

[00:17:53] Allie: What was the emotional state of having to navigate these bills? 

[00:17:57] Nicki: It was incredibly stressful because I had to pop into our little phone booth to have phone calls with health advocates, and attorneys work during the day. And it definitely detracted from time spent sitting at your desk to have conversations with people who could be helpful to you. 

[00:18:13] And on top of that, you have a family to take care of and groceries to buy. And I found that a lot of my evenings were spent sitting down researching things that really should not have been a good use of my time. So, it was just it was a really stressful 5 months because I didn’t know what the outcome would be. 

[00:18:32] I didn’t know that I would win this fight in the end, and it, it felt like kind of a Sisyphean effort of trying to like roll this boulder up the hill and not really sure that I was really going to get anywhere with it. And, I, during the time felt just so much empathy for the people who maybe work hourly jobs, where they can’t escape to a little phone booth to have a conversation with a health advocate to help them get guidance on how to get through this. 

[00:18:57] I’m grateful that The No Surprises Act has eliminated this stress and frustration for a lot of people, but there’s still so many instances that you hear of these sort of corner cases where hospitals are finding ways to work around the legislation to see what else [Music] they can pull off.  

[00:19:16] Allie: While The No Surprises Act is definitely a major step in the right direction, it’s clear that the legislation isn’t working perfectly quite yet. 

[00:19:26] It’s the federal government’s job to clearly communicate the protections, limitations, and potential gaps of The No Surprises Act, not just because it’s the right thing to do. Arming patients with this information can tremendously impact their ability to navigate the maze that is healthcare billing, giving people the ability to make informed decisions about their wellbeing, both in terms of health and finances. 

[00:19:55] It’s thanks to advocates like Dane and Nicki, that The No Surprises Act has been implemented on the national level, protecting millions of people from burdening the high costs of our healthcare system. While it’s clear that we still have a long way to go to repair our broken system, The No Surprises Act is a huge step forward in securing a future where healthcare is both transparent and accessible for everyone.  

 [00:20:24] We understand that a lot of people learn in different forms, so there will be a corresponding blog to this episode where we fully define the terms and also provide different tips and resources, whether they were mentioned today or in addition to that. So, check it out on empoweredus.org. We’ll link it in the show notes.  

[00:20:42] Also, if you found this episode to be informative and impactful, please share it with anyone else that you think may need to learn about this. It may fill in some of the gaps of their knowledge.  

[00:20:54] We at Empowered Us are committed to advocating for affordable healthcare for all. We look forward to continuing these conversations with patients and experts to both educate and create new solutions. Let’s keep pushing for change together. Take care and see you next time.   

[00:21:12] [Music Ends] 

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