Consumers Now Have Increased Protections from Unexpected Medical Bills

Pennsylvania Insurance Commissioner Jessica Altman reminded Pennsylvanians that the federal No Surprises Act legislation is now in effect and patients are protected from receiving surprise medical bills.

A surprise bill is an unexpected medical bill that a patient receives when they unknowingly or unintentionally obtain health care from a provider that is outside their plan’s provider network. Surprise bills can happen in emergency situations, but can also occur in a non-emergency situation, when an out-of-network ancillary provider such as an anesthesiologist or radiologist provides care at an in-network facility.

“The implementation of the No Surprises Act is a huge step toward ending unexpected and all-too-often financially devastating medical bills,” Altman said. “The Insurance Department is committed to protecting patients from balance billing and stands ready to assist consumers and insurers in navigating this new legislation.”

The No Surprises Act went into effect January 1. The new legislation protects patients from surprise bills by requiring that emergency services are billed as in-network, without needing prior approval, and certain non-emergency services at an in-network facility provided by out-of-network ancillary providers are also covered as in-network. In both situations, patients are responsible for no more than their in-network cost-sharing (like a deductible or co-pay) for the service. Patients should no longer be receiving surprise balance bills for more than this amount.

“Over the past few years, the insurance department has received numerous complaints about surprise bills,” Altman said. “The primary concern following major medical procedures should be recovery, not worry over medical billing.

“While the monetary cost of surprise balance bills is burdensome, so too is the fact that prior to these new protections, it has been consumers put in the middle and forced to navigate the complexities of medical billing in search of any reprieve,” Altman continued. “Which sometimes comes, but all too many times does not.”

In addition, the No Surprises Act bans certain other out-of-network charges and balance billing without advance notice. Health care providers and facilities are required to provide consumers with a plain-language consumer notice explaining that patient consent is required to get care on an out-of-network basis before that provider can bill the consumer.

The No Surprises Act protects individuals with coverage through their employer, Pennie™ (Pennsylvania’s state-based Marketplace), or directly through an individual market health insurance company. Other types of coverage, such as Medicare and Medical Assistance, already has protections from balance billing in place prior to January 1.

Patients who receive a surprise medical bill for services provided on or after January 1, 2022, should submit a bill review request to the Insurance Department at www.insurance.pa.gov/NoSurprises. When possible, consumers should contact the Department before paying a bill they believe may be a surprise bill or otherwise sent in error. The department’s dedicated consumer complaints team will verify the type of coverage the patient has and will reach out directly to the provider regarding the bill in question with the primary goal of ensuring the protections of the No Surprises Act are being met. Depending on the nature of the complaint, the department may have to work with the federal government or another commonwealth agency to help resolve the issue for the patient. Patients can also seek assistance from their health plan.

The Pennsylvania Insurance Department encourages patients to contact the department before paying a bill they believe has been sent in error or appears to not be consistent with the No Surprises Act. In addition to the website, the department can also be reached at 1-877-881-6388