Friday, August 8, 2025

Patient Rights and the Fight Against Surprise Billing: How the No Surprises Act Protects You

 


"Wherever the art of Medicine is loved, there is also a love of Humanity." — Hippocrates

Introduction: A Story You’ve Heard — But It’s Not Over Yet

Imagine this: Sarah, a healthy 35-year-old, visits an in-network hospital for a routine procedure. She carefully chooses her provider, checks her insurance, and breathes easy. Weeks later, an unexpected letter arrives—an out-of-network bill for $4,500 from the anesthesiologist she never met.

This surprise bill blindsided her, threatening her finances and peace of mind.

Sarah’s story is not unique. Surprise billing and balance billing remain a frustrating reality for millions of Americans—even after the No Surprises Act (NSA) came into effect on January 1, 2022.

This article unpacks everything busy medical professionals and patients need to know—how these laws work, expert insights, real stories, and tactical steps you can take today to avoid or resolve surprise bills.

Segment 1: Understanding Surprise Billing and Balance Billing — What You Need to Know

Surprise billing happens when patients unknowingly receive care from out-of-network (OON) providers during a visit to an in-network hospital or emergency room. Because patients often don’t control every specialist involved, bills can arrive for services they assumed were covered.

Balance billing is when an OON provider bills patients for the difference between their charge and what insurance pays. For example, if the insurer pays $700 but the provider charges $1,200, the patient can be billed the remaining $500.

Why Does This Happen?

  • Many hospitals contract only with a limited set of providers.
  • Providers like anesthesiologists, radiologists, or pathologists often operate independently.
  • Patients usually cannot confirm all involved providers’ network status at the time of care.
  • Insurance plans vary widely, and provider contracts can change frequently.

How Does the No Surprises Act Help?

The No Surprises Act is a landmark federal law that:

  • Prohibits balance billing for emergency care and most non-emergency care at in-network facilities.
  • Requires providers to give Good Faith Estimates of expected charges.
  • Establishes an Independent Dispute Resolution (IDR) process for payment disputes.
  • Protects patients from paying more than in-network cost-sharing amounts in covered situations.

The law applies to most commercial health plans and is enforced by the Departments of Health and Human Services, Labor, and Treasury.

Segment 2: Why Surprise Billing Still Happens — Gaps & Challenges

Despite NSA protections, gaps remain:

  • Ground ambulance services are mostly excluded, although some states have enacted their own protections.
  • Some non-emergency out-of-network providers can still balance bill with patient consent.
  • Billing errors and lack of transparency cause confusion and delays.
  • Enforcement and arbitration backlogs slow resolution and create system stress.
  • Many patients remain unaware of their rights under the law.

The system is improving but requires vigilance from patients, providers, insurers, and regulators alike.

Segment 3: Real-Life Patient Stories Highlighting Surprise Billing Issues

  • Erin (32, Brooklyn): Had an in-network C-section, but was billed $3,800 by an out-of-network pediatric anesthesiologist. She filed an NSA complaint and the bill was dropped.
  • Bryce (Hospital CFO): After implementing real-time insurance eligibility tools, surprise bills dropped by over 50% within six months.
  • Sarah (from intro): Lost trust in her hospital’s billing transparency but became empowered after learning about her NSA rights.

These stories demonstrate how surprise billing impacts everyday Americans and how awareness and advocacy can lead to resolution.

Segment 4: Expert Round-Up — What the Pros Say About Surprise Billing Chaos

Dr. Lisa Sanders, MD — Hospitalist & Clinical Ethicist

“Surprise billing is not just a financial failure — it’s an ethical failure. Vulnerable patients face catastrophic bills with no warning.”

Her advice:

  • Hospitals must fully disclose third-party out-of-network providers involved.
  • Providers should communicate billing information before discharge.
  • Patients deserve informed financial consent as much as clinical consent.

Marc Goldstein, JD — Healthcare Attorney & Policy Analyst

“The law is strong. The enforcement is weak. That’s the delta. Arbitrations are slow and often abused by both insurers and providers.”

His advice:

  • Providers: Document all billing disputes meticulously.
  • Patients: Use CMS’s NSA complaint portal actively.
  • Leadership: Promote pre-arbitration negotiation to ease system strain.

Dr. Rita Mehta — Medical Billing Specialist & Revenue Cycle Strategist

“Most surprise bills aren’t malicious — they’re mistakes. Up to 80% of surprise bills stem from coding errors or outdated payer information.”

Her advice:

  • Use real-time eligibility checks.
  • Flag OON services at patient check-in.
  • Automate cost estimators integrated with scheduling.

Segment 5: Tactical Tips to Outsmart Surprise Billing — What You Can Do Right Now

For Patients:

  • Ask every provider: “Are you in-network?”
  • Request a Good Faith Estimate before procedures.
  • Know NSA exclusions (e.g., ground ambulances).
  • Review all Explanation of Benefits (EOBs) carefully.
  • File complaints via CMS NSA complaint portal.

For Providers and Practice Managers:

  • Audit billing processes quarterly.
  • Train front desk on network checks and disclosures.
  • Use real-time insurance eligibility verification.
  • Flag OON risks clearly in patient records.
  • Update intake forms with hold harmless and disclosure language.
  • Assign a dedicated billing advocate to assist patients.

For Health Systems and Leaders:

  • Conduct “surprise billing fire drills” simulating patient scenarios.
  • Publish transparency dashboards on billing.
  • Invest in patient education via videos, guides, and online tools.

Segment 6: Frequently Asked Questions (FAQs)

1. What is a surprise medical bill?

Unexpected charges from OON providers during in-network visits.

2. How is balance billing different?

It’s billing the patient for the difference between provider charge and insurance payment.

3. What does the No Surprises Act cover?

Emergency care, non-emergency care at in-network facilities, and air ambulance transport, among others.

4. Are ground ambulance rides covered?

Generally no, except where states have specific laws.

5. How to dispute a surprise bill?

Use the CMS complaint portal or IDR process.

6. Can I be balance billed if I signed a waiver?

Potentially yes, but waivers must be clear, voluntary, and given 72 hours in advance.

7. Do these rules apply to Medicare/Medicaid?

No, these programs already prohibit balance billing.

Segment 7: Expert Opinions & Real-Life Commentary

Dr. Allison Ramirez, Emergency Physician

“Network status is a luxury in the ER—patients come for care, not contracts.”

Advocates for billing checklists and early billing team alerts.

Professor Samuel Lee, Health Policy Scholar

“NSA helped, but repeat arbitrations and underreporting persist.”

Calls for data-driven enforcement and limiting abusive arbitration.

Maria Alvarez, Billing Advocate

“Billing mistakes affect 60% of surprise bills. Providers must own clarity.”

Recommends pre-bill reviews and educating patients not to pay blindly.

Segment 8: Myth-Buster Recap & Final Push

Myth

Reality

Insurance fully protects against surprise bills

Many surprise bills still occur despite insurance

NSA fixed all surprise billing

NSA has gaps; some services excluded

Providers always bill correctly

Errors are common; patients should review bills

Patients must pay surprise bills

Many bills can and should be disputed

Complaints don’t work

Complaints often result in refunds or corrections

Call to Action: Get Involved — Be the Change

  • Raise your hand: Share your billing story.
  • Join the conversation: Engage with advocacy groups.
  • Support transparency: Demand clear cost disclosures.
  • Use your voice: Contact legislators for stronger enforcement.
  • Claim your spot: Become an informed patient or advocate.

Final Thoughts

Surprise billing thrives in silence — your voice is the first step to ending it.
Transparency isn’t a luxury — it’s a right every patient deserves.
Together, we can turn confusion into clarity and bills into fairness.

References

No Surprises Act Enforcement & Analysis

About the Author

Dr. Daniel Cham is a physician and medical consultant specializing in medical tech consulting, healthcare management, and medical billing. He delivers practical insights to help healthcare professionals navigate complex challenges at the intersection of clinical care and billing transparency. Connect with Dr. Cham on LinkedIn:
https://linkedin.com/in/daniel-cham-md-669036285

Hashtags

#NoSurprisesAct #PatientRights #HealthcareTransparency #MedicalBilling #BalanceBilling #HealthcarePolicy #PatientAdvocacy #MedicalBillingReform #HealthLaw #HealthcareManagement

 

 

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