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Surprise Medical Billing

NO SURPRISES ACT (NSA): A new law that protects you from excessive, unexpected, out-of-pocket medical costs.

If you have group or individual health insurance coverage, you now have new protections from receiving surprise medical bills after receiving medical care or services from an out-of-network provider that you did not choose or authorize.

This is most common in emergency situations when a patient has to go to the nearest emergency department and the emergency department is considered out-of-network under the patient’s insurance plan. It can also occur when a patient is treated at an in-network hospital or facility, but one of the specialists or other caregivers involved in the treatment are out-of-network for the patient’s insurance plan.

“Out-of-network” means the provider does not have a signed contract with your health plan. Common provider types where this may happen include anesthesiologists, pathologists, radiologists, hospitalists, surgical assistants, intensivists and laboratories.

What is a surprise medical bill?

In-network providers have negotiated with your insurance company and agreed to accept a certain amount as payment in full for the services they provide.

Out-of-network providers have no such agreement and, before the NSA was enacted, were allowed to bill consumers for the difference between the amount the insurer paid and the amount the provider charged. This is referred to as “balance billing” and, under the new law, is no longer allowed in certain situations.

The NSA protects you from surprise medical bills by:

  • Prohibiting doctors, hospitals, and other covered providers from billing patients more than the in-network costs for medical services and devices provided at in-network facilities or in relation to emergency services.
  • Requiring health insurance providers to cover the balance due for out-of-network claims for services provided in emergency situations or at in-network facilities.
  • Establishing an independent dispute resolution (IDR) process if the health insurance company and health provider cannot negotiate an agreed upon cost for out-of-network services.
  • Ensuring that any amount you pay for emergency services and/or out-of-network services delivered at in-network facilities will count toward your deductible and annual or lifetime out-of-pocket limit.

For questions or more information about your rights under the No Surprises Act (NSA), visit Cms.gov/NoSurprises/Consumers, Ohio.gov or call 866-771-7266.