Surprise Billing

An unexpected medical bill a patient receives when they unknowingly receive care from an out-of-network provider, particularly in emergency situations or at in-network facilities.

Surprise billing became a national issue because patients were getting hit with enormous bills they did not expect. The classic scenario: you go to an in-network hospital for surgery, your surgeon is in-network, but the anesthesiologist who was assigned to your case is out-of-network. You get a $15,000 bill from the anesthesiologist because they can charge their full fee since they have no contract with your plan. The No Surprises Act, effective January 1, 2022, addressed this. The law protects patients from surprise bills in three main situations: emergency services at any facility regardless of network status, non-emergency services provided by out-of-network providers at in-network facilities when the patient did not choose the out-of-network provider, and air ambulance services. In these situations, the patient pays only their in-network cost-sharing amount. The out-of-network provider cannot balance bill the patient. Instead, the provider and the payer must negotiate the payment, and if they cannot agree, they go through an independent dispute resolution (IDR) process where an arbitrator decides the payment amount. For credentialing, the No Surprises Act makes network participation more important than ever for facility-based specialists like anesthesiologists, pathologists, radiologists, and emergency physicians. Being out-of-network at an in-network facility used to be lucrative because you could charge your full fee. Now, your payment is determined by negotiation or arbitration, which often results in less than what you would have billed. Providers who are not in-network must provide patients with a good faith estimate of charges before scheduled services. If the final bill exceeds the estimate by more than $400, the patient can dispute the charges through a patient-provider dispute resolution process. The practical impact: if you are a facility-based provider, get credentialed with the same payers your facility is credentialed with. And if you choose to stay out-of-network, understand the IDR process and be prepared to use it, because that is now how your payment gets determined.