Is your medical bill a violation of the No Surprises Act?

No Surprises Act

Part 2 of our No Surprises Act series 

The HHS Office of the Assistant Secretary for Planning and Evaluation released a report that shows nearly one in five patients with private insurance who go to the emergency room, have an elective surgery, or give birth in a hospital receive surprise bills. The average cost ranges from $750 to $2,600 per episode. 

Not a fun surprise. 

The No Surprises Act protects consumers from surprise medical bills in the U.S.—but no law is cut and dried. In part 1 of our series, we gave an overview of the new law and its protections. Now we’ll go over how to determine if a bill is a violation, what to do if you think it’s one, and share online resources for consumers. 

Surprise medical bill? It could be a violation of the No Surprises Act. 

It’s never a good feeling to receive a surprise medical bill. Once the shock wears off, it’s time to do some research to see if that bill is a mistake or a violation. But how do you know if the bill you’ve received from a healthcare provider is in violation of the No Surprises Act?

For insured consumers, a bill must meet three criteria to be considered a possible violation of the No Surprises Act: 

  1. They received a surprise medical bill. 
  1. The insurance plan year start date is on or after Jan. 1, 2022. 
  1. The items or services associated with the disputed bill are covered benefits under the health insurance plan.  

Uninsured consumers also have three criteria to meet for a bill to be considered a possible violation: 

  1. The date of service was on or after Jan. 1, 2022. 
  1. The appointment for the bill being disputed was scheduled by the consumer. 
  1. The services were provided by either a healthcare facility or healthcare provider. 

You have a surprise medical bill – now what do you do? 

If a medical bill meets criteria as being a surprise bill, it’s time to take action.  

Both federal and state governments enforce the No Surprises Act. Some states share the responsibility with the federal government while others do not have the means to take it on themselves.  

So where do you go for help? The Centers for Medicare & Medicaid Services No Surprises Help Desk answers questions and takes complaints from consumers.  

You’ll need documentation to accompany your complaint. Some examples include: 

  • Bill pertaining to the date of service you are disputing, 
  • Explanation of benefits (EOB) pertaining to the date of service you are disputing 
  • Copy of your insurance card 
  • A good faith estimate (if uninsured or self-pay) 
  • Your health insurance plan year’s start date.  

It’s also important to know that the No Surprises Act protects people from the negative side effects of unlawful debt collection and credit reporting. You do not need to be a Medicaid or Medicare customer to ask for help from the CMS Help Desk. 

Online No Surprises Act Resources

Notices you may get and whether you should sign them

Where to go for help (state or federal map)

How we are protecting people from the side effects of surprise medical bill

CMS Online complaint form