Medical treatment and care can be ruinously expensive. And for Americans without insurance, it’s even more financially challenging. The uninsured often have to pay the list price of treatments, sometimes two to five times higher than the cost to those who are privately insured.
Until this year, the uninsured and other patients paying for their treatments out of their own pocket (“self-payers”) could rarely get a cost estimate for their planned medical care. They were, however, expected to pay the bill after they received it. For self-payers, this meant financial planning for medical expenses was almost impossible and, as a result, increased their chances of incurring medical debt and possibly being subject to debt collectors and lower credit scores.
Now, a new law ensures that self-payers can get a written cost estimate for planned medical procedures.
The No Surprises Act, which went into effect in January 2022, entitles patients to a written “good faith estimate” of the cost of a planned procedure or care.
For those without insurance or for those paying for care that is not covered by insurance, health care professionals and facilities must give patients a written good faith estimate based on the “reasonably expected” costs of a procedure.
(NOTE: The law dictates that at some point in the near future, Americans with insurance will get a document called an “Advanced Explanation of Benefits” which includes this estimate from their insurer. This part of the law is not yet in effect and the start date is yet to be determined.)
How do I get a good faith estimate for medical care?
You are entitled to a good faith estimate from your health care professional (for example, the doctor) and from the health facility (for example, the hospital or surgery center).
- If you schedule your appointment between 3 and 10 days in advance of the procedure, the providers (doctor and health facility) must give you a written estimate within one business day of scheduling it.
- If you schedule care more than 10 days in advance of your treatment, you can expect a reply within 3 business days of scheduling.
- Even if you do not schedule an appointment, you can ask for a written good faith estimate and the health providers are required to provide it.
- If you do not receive the estimate that you are entitled to by law, call the Surprise Billing hotline at 1-800-985-3059.
- Be sure the good faith estimate includes all of your expected care. Remember to check for additional services you might need, such as testing, imaging, anesthesiology, recovery medications, ICU care and more.
- If you have multiple appointments scheduled, the estimate will only include the “primary” procedure and associated medical care. If part of your care is scheduled separately (such as a pre-surgical exam), or with another provider (such as an additional specialist), be sure to get a written estimate for that separate care or different provider. The good faith estimate should clearly list each service and medication with its associated cost.
- Keep your written estimates in a safe place so you can compare it with the bills you receive after treatment. Here’s an example of a blank good faith estimate.
- Keep all of the bills you receive relating to your care with the good faith estimates you received, in case you need to dispute your bill.
What if I have questions?
By law, providers must answer your questions and explain your good faith estimate. Do not hesitate to reach out to your provider or health care facility if you have questions about specific charges.
What do I do if my bill is more than my good faith estimate?
If your bill is more than $400 higher than the good faith estimate, you can challenge it with this form. A good faith estimate is not a bill, so the actual cost of a procedure may not be the same as the estimate. There is a $25 fee to use the dispute process, and you will need your bills and the written estimate to file the dispute.
- You must file a dispute within 120 calendar days (about 4 months) of the date of the bill.
- To dispute any bill, you need to have both the good faith estimate and the bills you received after your care. Here are additional tips to help you understand how to challenge an overcharge.
Health insurance and billing can be confusing. Use this list of common terms to understand what you are reading.
If you need more information, try these additional government resources.
Photo credit: @nci on Unsplash
Director, Health Care Campaigns, U.S. PIRG Education Fund
Patricia directs the health care campaign work for U.S. PIRG and provides support to our state offices for state-based health initiatives. Her prior roles include senior director of health policy with the National Consumers League, senior policy advisor at NJ Health Care Quality Institute, and consumer advocate at NJPIRG. She serves on the board of the Patient and Caregiver Engagement Advisory Group for the National Quality Forum. Patricia enjoys walks along the Potomac and sharing her love of books with her friends and family around the world.