On Jan. 1 of this year, the No Surprises Act (NSA) went into effect protecting individuals with private health insurance from surprise medical bills. In other words, if you are insured from a company that is not Medicare or Medicaid and receive emergency medical care or a scheduled procedure at an in-network facility, then, in most circumstances, you will not be billed at “out of network” rates. This law, signed by President Donald Trump in 2020 and now being implemented under President Joe Biden, goes a long way in protecting consumers from what the industry calls “balance billing.”
The No Surprises Act is likely one of the most significant bipartisan laws protecting American healthcare consumers in more than a decade. This law helps protect the consumer from getting caught in the crossfire between healthcare providers and insurance companies and gives them important protections that can often shield them from financial ruin or bankruptcy from surprise medical bills.
It is important to note this new law also protects self-payers and the uninsured. A self-payer is simply someone who pays their own medical expenses directly. While those without traditional health insurance do not have provider or facility networks, the NSA still has provisions to protect consumers from unanticipated medical costs. The NSA requires medical providers to give patients a Good Faith Estimate of the cost of scheduled care before the service is provided. The Good Faith Estimate will be provided to all self-pay and uninsured patients and is a good tool when shopping for lower-cost services.
For the self-pay and uninsured, if the services provided exceed the Good Faith Estimate by $400 or more, patients can dispute the charges. In most cases, it makes sense to first dispute the discrepancy with your medical service provider. If you are unable to resolve this dispute with the provider, the U.S. Department of Health and Human Services (HHS) in conjunction with the Centers for Medicare and Medicaid Services (CMS) provide a Patient-Provider Dispute Resolution (PPDR) service.
The PPDR program will engage a third party to arbitrate the dispute and will resolve the bill to the amount of the estimate, the billed amount, or somewhere in the middle depending on the circumstances. To start the dispute process, there is a $25 administrative fee that will be paid by the individual making the claim. This process provides a valuable tool for those who are unable to afford health insurance or who self-pay for their medical services.
For more information, contact our office at CSIMT.gov, 406-444-2040, or go to the CMS website at www.cms.gov/nosurprises/consumer or call 800-985-3059.
Troy Downing is the Republican Montana State Auditor.