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If you have health insurance and are planning medical care, you probably know that you should choose a doctor and hospital that are part of your health plan network.
If you don’t, you are going to end up paying more for your care.
Providers in your health plan network (sometimes called “participating providers” or “preferred providers”) have negotiated a payment rate with your insurer and you’ll only be financially responsible for your co-pay, co-insurance and deductible. But out-of-network doctors (“nonparticipating providers”) don’t have a negotiated rate with your insurance plan and can charge whatever they want. Your health plan will cover only part of that bill. And you’ll owe the rest – that’s called a balance bill. Sometimes it’s called a surprise bill.
Under the No Surprises Act, you have new protections from surprise bills. But if you aren’t careful, you might give up those rights if you sign the “Surprise Billing Protection Form.” Here’s what you need to know.
What are “surprise bills” and what are my protections?
A surprise bill is another word for a “balance bill.” It is what you owe for health care you received from an out-of-network provider. Surprise bills can cost you hundreds or thousands of dollars. Before 2022, even patients who were careful to use in-network providers (“participating providers”) sometimes ended up with a surprise bill. But under a new federal law, the No Surprises Act, you should never receive a surprise bill when:
- you receive care in the emergency room
- you are transported by an air ambulance (airplane or helicopter)
- you receive care at in-network health care facilities
But there are some situations when an out-of-network doctor might ask you to sign a “Surprise Billing Protection Form.” It might come in the stack of forms you are given when scheduling your care. It should look something like this sample form.
If you sign that form, you’re giving up your protections from expensive surprise bills. You are agreeing to allow that out-of-network provider to send you a bill for anything your insurance won’t cover.
So before you sign a “Surprise Billing Protection Form,” think carefully and be sure you understand it.
Important: You should never be given a Surprise Billing Protection Form if you’re being treated for an emergency.
Who can ask me to sign the “Surprise Billing Protection Form”?
The two most common times you may be asked to sign a Surprise Billing Protection Form is when you are scheduling hospital care, like a surgery, or when you’re already in the hospital and you need some sort of unexpected care.
You must be given the form at least 72 hours before a scheduled procedure. For care that is scheduled for the same day, the form should be provided at least 3 hours before a procedure.
These providers are not allowed to ask you to sign this form.
- Emergency rooms or their physicians
- Assistant surgeons
- Radiologists or imaging services at your in-network hospital
If you are asked to sign the form by any of these providers or anytime you are receiving emergency care, DO NOT sign the form and immediately report this violation by calling the No Surprises complaint line at 1-800-985-3059 or file a complaint at https://www.cms.gov/nosurprises/consumers/complaints-about-medical-billing
Important: You always have the right to ask for an in-network provider if you are at an in-network health care facility. You should never be pressured to sign the form.
How can I keep my medical costs lower?
Always try to use hospitals and doctors that are part of your health plan’s network.
If you receive care from a nonparticipating provider (a hospital or doctor who is not in your health plan’s network), you will almost always be billed more than if you had seen an in-network provider. To keep costs lower, choose a participating provider. Your health plan can help you find one.
Before being treated by any provider, be sure that you ask “Are you in-network with my insurance plan?”. Don’t ask “Do you take my insurance?” because even nonparticipating providers will accept some insurance payments, but they can still bill you for the remaining unpaid amount.
Should I sign a “Surprise Billing Protection Form”?
We generally recommend that patients not sign the Surprise Billing Protection Form. Here’s why:
When you sign the Surprise Billing Protection Form, you agree to give up all of your billing protections under the No Surprises Act. This means that you will be billed for and responsible to pay any amount above what your insurance pays that out-of-network provider.
Important: The amounts that you pay a nonparticipating provider do not count toward your deductible.
- Read all parts of the Surprise Billing Protection Form. Ask questions if you don’t understand it.
- Ask the facility or your insurer for a list of in-network providers you can use instead. By choosing a participating provider, you will limit your out-of-pocket costs.
- It is illegal for certain providers to ask you to sign a Surprise Billing Protection Form: emergency rooms or their physicians, assistant surgeons, anesthesiologists, radiologists or imaging services at your in-network hospital, hospitalists, intensivists, pathologists,and neonatologists. DO NOT sign the form and immediately report this violation to the No Surprises complaint line at 1-800-985-3059 or https://www.cms.gov/nosurprises/consumers/complaints-about-medical-billing
- Review the page that provides a cost estimate. Ask if it contains all of the out-of-network costs you can expect..
Signing this form means:
- You are giving up all of your protections under the No Surprises Act.
- The out-of-network provider will bill you for the services that you receive. This bill should be similar to the cost estimate provided to you on the Surprise Billing Protection Form.
- The amount you pay the out-of-network provider will not count towards your deductible, and may not count towards your out-of-pocket limit.
- You will pay more than if you receive care from an in-network provider.
You might consider signing the form if:
- you have a relationship with the provider asking you to sign it and you are willing to pay more for your care.
- you selected this doctor for their expertise and you are willing to pay more for your care.
Remember, you can always reach out to your insurance provider to find provider who is part of your health plan’s network. This will prevent you from being billed anything more than your expected co-pay, co-insurance and deductible.
If you decide to sign:
- Take a picture and keep a copy of the form for your records.
- This form contains information about your rights and protections, and how to make a complaint. Refer back to it once you receive the bill from the out-of-network provider.
What do I do if my medical bill looks wrong?
If your bill looks wrong, it very well might be! So always call your provider and your insurer and ask questions about your bill. Ask for an itemized list of charges.
If you have been directly billed by a non-participating (out-of-network) provider and did not sign the Surprise Billing Protection Form for that provider, this may be an illegal surprise bill. Check your rights under the No Surprises Act. Contact both your insurer and provider immediately. If they continue to ask you to pay, you should file a complaint at the No Surprises complaint line at 1-800-985-3059 or visit https://www.cms.gov/nosurprises/consumers/complaints-about-medical-billing.
Senior 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 policy advisor at NJ Health Care Quality Institute, associate state director at AARP New Jersey and consumer advocate at NJPIRG. She was appointed to the Ground Ambulance and Patient Billing Advisory Committee in 2022 and works with patient advocates across the U.S. Patricia enjoys walking along the Potomac River and sharing her love of books with friends and family around the world.
PIRG health care intern, Fall 2022