How to challenge a surprise medical bill in the US

The No Surprises Act protects consumers from unexpected medical bills from out-of-network providers during emergencies or non-emergency services at in-network facilities. Learn how to identify, dispute, and appeal these protected bills under federal law.

Step-by-step playbook

  1. Identify a surprise bill — Check if your bill is from an out-of-network provider for emergency services or non-emergency services at an in-network facility, or if you were not given proper notice and consent [S1, S3].
  2. Gather documentation — Collect the bill, your Explanation of Benefits (EOB), any Good Faith Estimates, and any signed consent forms [S3, S4, S5].
  3. Contact your provider/insurer — Call your health plan or the provider's billing department to explain why you believe the bill violates the No Surprises Act and request a correction [S5].
  4. File a formal complaint — If unresolved, file a complaint with the Centers for Medicare & Medicaid Services (CMS) or your state's insurance department. Initiate this within 120 calendar days from the bill date for Good Faith Estimate disputes [S4, S6].
  5. Consider patient-provider dispute resolution — If uninsured/self-pay and your bill is at least $400 more than your Good Faith Estimate, you can start a dispute resolution process within 120 calendar days of the bill date [S4].

Your rights

Who to contact

Your rights

Under the No Surprises Act, which went into effect on January 1, 2022, you are protected from many types of surprise medical bills [S1]. This law prohibits balance billing for certain out-of-network services [S1]. Specifically, you are protected from surprise bills for emergency services, even if you receive them out-of-network without prior authorization [S2]. For non-emergency services, if you receive care from an out-of-network provider at an in-network hospital or ambulatory surgical center, you are generally only responsible for the in-network cost-sharing amount [S1, S2]. Out-of-network providers and facilities are typically forbidden from billing you for the difference between their charge and the amount your plan pays (balance billing) for these protected services [S1].

Before you receive non-emergency services from an out-of-network provider at an in-network facility, the provider must give you a notice and obtain your consent to waive your No Surprises Act protections [S3]. Without this consent, you cannot be balance billed [S3]. You also have the right to receive a 'Good Faith Estimate' of expected charges if you are uninsured or choose not to use your insurance [S4]. This estimate must be provided within specific timelines: typically within 3 business days of scheduling a service at least 10 business days in advance, or within 1 business day for services scheduled at least 3 business days in advance [S4].

How to dispute

If you receive a surprise medical bill that you believe violates the No Surprises Act, your first step should be to contact your health plan or provider [S5]. Explain that you believe the bill is a surprise bill covered by the No Surprises Act and request a correction [S5]. Gather all relevant documentation, including the bill itself, any Explanation of Benefits (EOB) from your insurer, and any consent forms you may or may not have signed [S3, S5].

If contacting the provider or plan does not resolve the issue, you can file a complaint with federal or state authorities [S5, S6]. The government agencies responsible for enforcing the No Surprises Act include the Centers for Medicare & Medicaid Services (CMS) and your state's insurance department [S5, S6]. You can report a surprise bill online or by phone [S6]. For privately insured individuals, specific federal protections apply [S1]. If you are uninsured or self-pay and received a bill substantially higher than a Good Faith Estimate (at least $400 more), you can initiate a patient-provider dispute resolution process [S4]. You must initiate this process within 120 calendar days from the date on the bill [S4].

Common traps

One common trap is inadvertently signing a consent form to waive No Surprises Act protections without fully understanding its implications [S3]. Always read any forms carefully before signing them, especially those related to out-of-network services [S3]. Another trap is assuming all out-of-network bills are covered. The No Surprises Act has specific protections, and not every out-of-network service is included [S1]. For example, ground ambulance services are not covered by the No Surprises Act, though air ambulance services are [S7]. Be aware of the scope of the law to understand your exact protections.

Failing to request a Good Faith Estimate when uninsured or self-pay can also be a trap, as it limits your ability to dispute substantially higher bills later [S4]. Always ask for this estimate in writing. Lastly, delaying action can be detrimental. There are deadlines for initiating disputes, such as the 120-day window for patient-provider dispute resolution [S4].

When to escalate

Escalate your dispute if your direct communication with the provider or insurer does not lead to a resolution [S5]. This means filing a formal complaint with the appropriate government agency [S6]. For most surprise billing issues, this will be CMS or your state's insurance department [S6]. These agencies can mediate or investigate your complaint and ensure compliance with the No Surprises Act [S5]. If your bill differs significantly from a Good Faith Estimate, and you've tried to resolve it directly, the patient-provider dispute resolution process through a certified independent dispute resolution entity is the next step [S4]. Keep detailed records of all communications, including dates, names, and what was discussed, as this will be crucial for escalation [S5]. If you suspect fraudulent billing practices, you should also report this to relevant authorities [S8].

Sources

  1. The No Surprises Act | CMS
  2. What does the No Surprises Act do? - Consumer Financial Protection Bureau
  3. Surprise Medical Bills: What You Need to Know | HHS.gov
  4. Good Faith Estimates for Uninsured (or Self-Pay) Individuals | CMS
  5. No Surprises Act: How to Dispute a Bill | kff.org
  6. How to file a No Surprises Act complaint | CMS
  7. Understanding the No Surprises Act: The Scope of Air Ambulance Protections | The National Law Review
  8. Report Health Care Fraud | HHS Office of Inspector General

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