Jan has private health insurance through her work; she went to an in-network hospital, did everything right, and six weeks later got a bill from an anesthesiologist she'd never met, who turned out to be out-of-network, leaving her with a $2,500 hole in her purse. Before 2022, that bill was not only legal but common. Nowadays, though, patients like Jan have more protection under the No Surprises Act (NSA). And, believe it or not, according to a KFF poll, 78% of Americans know little or nothing about the NSA and how it protects them.

The NSA took effect on January 1, 2022, and applies to private health plans (including employer-sponsored coverage, as well as marketplace and individual plans). At its core, the NSA takes the patients out of the middle of the tug-of-war between billing providers and insurance companies. The provider and the insurer settle the bill between themselves. Since 2010, the Affordable Care Act (ACA) has required private health plans to cover out-of-network emergency care at in-network cost-sharing rates, but the out-of-network physician could still balance-bill you for the rest; the NSA closed that gap. A balance bill is a bill sent directly to the patient that covers the difference between what the provider charged and what your insurance paid.

Emergency Care, Anywhere: Hospital emergency rooms (ERs) and freestanding ERs (in-network or out-of-network) are covered. You pay the in-network cost-sharing price, no matter what. This protection granted by the NSA lasts into post-stabilization care until specific conditions are met.

Non-Emergency Care From Out-of-Network Providers at an In-Network Facility: The out-of-network radiologist reading your x-ray and the out-of-network anesthesiologist during your in-network surgery cannot bill you out-of-network rates. This applies to in-network hospitals, hospital outpatient departments, and ambulatory surgery centers, whether you're admitted, on observation, or outpatient.

Air Ambulance, Anytime.

In each case, you can be billed no more than your in-network cost-sharing (deductible, copay, and coinsurance), and it counts toward your in-network deductible and out-of-pocket max.

Florida Note: Before the NSA was proposed, Florida had its own state protections that prohibited certain out-of-network providers from balance-billing certain patients; however, the NSA is a much more inclusive means of protection.

There is a notice-and-consent form that lets an out-of-network provider waive your NSA protections and balance-bill you. It's only allowed for certain non-emergency care situations and must be given in advance (at least 72 hours, or 3 hours for same-day services), be separate from the admission paperwork, include a cost estimate and in-network alternatives, and state that you're not required to sign.

It cannot be given if you are getting emergency care (except post-stabilization under very strict conditions) and cannot be given by ancillary providers in any situation (ancillary providers include emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, lab services, and imaging services). It's also banned when no in-network provider is available.

So, if an anesthesiologist or radiologist asks you to sign away your NSA protections, that form can't do it.

If you refuse to sign the notice-and-consent form, the out-of-network provider may decline to treat you unless it's an emergency, in which case you can't be refused treatment. You would then need to find an in-network provider.

In a sentence, read everything you sign at admission, and don't sign anything with "consent to out-of-network" language without understanding the pros and cons.

If you're uninsured or choose not to bill your insurance for a service, a Good Faith Estimate (a written estimate for scheduled care booked at least 3 business days in advance, or at your request) must be provided to you. If the final bill is $ 400 or more above the estimate, you can dispute it through the patient-provider dispute resolution process, typically within 120 days of receiving the bill. An insured-patient version of this cost estimate form is written into law, but still isn't in effect (advanced explanation of benefits).

Regrettably, I can confirm that fighting for your rights under the NSA is neither simple nor easy, but it is necessary, not just for yourself and your bank account, but for the millions of other patients who may go through a similar billing experience. Billing errors happen; we're all human. I don't want a takeaway to be that all violators are malicious. Either way, though, the bill isn't yours to pay. Here's what to do if you get a surprise bill:

Remember how I said the NSA was designed to keep you out of the tug-of-war match between the insurer and the provider? I'm still going to tell you a bit about it, because knowledge is power. Essentially, the out-of-network provider and insurer negotiate the price for 30 business days; if a price isn't settled, the case can go to independent dispute resolution. Both parties submit an offer, and an arbiter (kind of a judge, but not really) picks one within 30 business days. The decision is binding. None of this changes what you owe; your cost-sharing is set separately. This does change something, however. Providers have been winning the majority of these disputes, which may be helping increase insurance premiums over time.

A surprise medical bill is exactly the kind of event that can wreck stability, and the NSA is a shield most people don't know they're holding. If you've received a hospital bill recently, check out my Hospital Bill Checklist, which is a free, easy-to-use guide on what to do before you pay a hospital bill. Subscribe for more.