Medical treatment and dental 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 or dental care. They were, however, expected to pay the bill after they received it. For self-payers, this meant financial planning for medical and dental 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 and dental 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 medical or dental 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 and dental care?
You are entitled to a good faith estimate from your health care professional (for example, the doctor or dentist) 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 (doctors and health facilities) 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.
- Be sure your written estimate includes: your name, the name of the doctor or health facility is providing the estimate, the medical codes of the care with a short description, and the total amount you will owe. If your estimate does not include all of this information, ask for a new written estimate that includes all of this information.
- 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 the bill using the Patient-Provider Dispute Resolution process. Use this form. You will need to submit a copy of your bills and the written good faith estimate to file the dispute.
A good faith estimate is not a bill, so the actual cost of a procedure may not be the same as the estimate, but you can contest any amount that is more than $400 over the estimate.
If you use the Patient-Provider Dispute Resolution system, you will pay a $25 fee. This fee will be taken off of your final medical bill, if you win the dispute.
Don’t delay: You can only dispute bills that are dated within the last 120 calendar days (about 4 months).
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
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 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.