Patient Rights Regarding Surprise Medical Bills
What is the No Surprise Act?
The No Surprise Act was established to protect patients who receive health insurance coverage through their employer (including a federal, state, or local government), through the Health Insurance Marketplace®, or directly through an individual health plan from being balanced billed for services when they are treated by a non-contracted provider or facility in the scenarios defined below:
- Surprise billing of emergency services is prohibited. Even if emergency services are provided out-of-network, they must be covered at an in-network rate and without prior authorization.
- Balance billing and out of-network cost sharing (like copayments or out-of-network coinsurance) are prohibited for emergency services and certain non-emergency services. These situations can not result in the patient paying a higher cost than if the services were provided by an in-network provider. Any coinsurance or deductible must also be based on rates at in-network providers.
- Prohibits out of-network charges and balance billing to ancillary care provided by out-of-network physicians at an in-network facility.
- Without advance notice, certain out-of-network charges are prohibited, as well as balance billing.
- Before any health care provider or facility can bill a patient, they must first provide a plain-language notice to the patient explaining that consent is required in order to receive care on an out-of-network basis. They also need to ask for consent and give a good faith estimate within the allotted time frame.
- For patients without insurance (uninsured, self-pay), this ensures that the patient knows the cost of their healthcare before they receive it. This also allows them to file a dispute if the bill is higher than $400.00 of the estimate.
- The rules do not apply to patients with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE because these programs have other protections which do not allow balance billing.
We understand that this new rule can cause many questions and/or concerns. We can help you navigate the billing process. If you have any questions, please contact our financial counselor.
Lone Star Orthopaedic and Spine Specialists, PLLC
Main Phone: (817) 926-2663
Main Fax: (817) 293-8860
215 Old Highway 1187
Burleson, TX 76028
Fort Worth Office
929 Lipscomb Street
Fort Worth, TX 76104
167 Regency Parkway, Suite #103
Mansfield, Texas 76063