Your Rights and Protections Against Surprise Medical Bills
Understanding Your Rights as a Patient
Federal law protects you from unexpected medical bills, also known as surprise medical bills or balance billing, when you receive emergency medical care or certain services from an out-of-network provider at an in-network hospital or ambulatory surgical center.
In these situations, you generally cannot be charged more than your health insurance plan’s in-network cost-sharing amounts, such as copayments, coinsurance, and deductibles.
What Is Balance Billing?
When you receive medical care, you may be responsible for certain out-of-pocket expenses, including copayments, coinsurance, or deductibles.
Healthcare providers and facilities are considered in-network when they have an agreement with your health insurance plan. Providers and facilities that do not have such an agreement are considered out-of-network.
When you receive care from an out-of-network provider, you may be charged the difference between the amount your insurance plan pays and the total amount billed by the provider. This is known as balance billing.
These additional charges can be significantly higher than in-network costs and may not count toward your annual deductible or out-of-pocket maximum.
What Is Surprise Billing?
Surprise billing occurs when you unexpectedly receive care from an out-of-network provider, often in situations where you have little or no control over who provides your medical services.
For example, you may schedule a procedure at an in-network ambulatory surgical center but receive anesthesia services from a provider who is not part of your insurance network.
Depending on the services provided, unexpected medical bills can result in substantial additional expenses.
The federal No Surprises Act provides important protections to help prevent these situations.
When Are You Protected from Balance Billing?
Emergency Medical Services
If you experience a medical emergency and receive treatment from an out-of-network provider or facility, you generally cannot be charged more than your insurance plan’s in-network cost-sharing amount.
These protections also apply to certain services you receive after your condition has stabilized, unless specific legal requirements are met and you voluntarily provide written consent to waive those protections.
Certain Services at an In-Network Hospital or Ambulatory Surgical Center
When you receive care at an in-network hospital or ambulatory surgical center, some of the healthcare professionals involved in your treatment may be out-of-network.
Under federal law, you are protected from balance billing for certain services provided by these professionals, including:
- Anesthesia
- Emergency medicine
- Pathology
- Radiology
- Laboratory services
- Neonatology
- Assistant surgeon services
- Hospitalist services
- Intensivist services
For these services, you generally cannot be charged more than your in-network copayments, coinsurance, and deductibles.
Providers offering these services cannot require you to waive your balance billing protections.
For certain other services at in-network facilities, an out-of-network provider may be permitted to balance bill you only if you voluntarily provide written consent that meets federal requirements.
Important: You are never required to give up your protections against balance billing. You also have the right to choose healthcare providers and facilities that participate in your insurance network.
Additional Patient Protections
When balance billing is prohibited, you have the following rights:
- You Are Responsible Only for Your In-Network Cost-Sharing Amounts
You are generally responsible only for the copayments, coinsurance, and deductibles you would have paid if the provider or facility had been in-network.Your health insurance plan is responsible for paying any additional covered amounts directly to the out-of-network provider or facility.
- Emergency Services Must Be Covered Without Prior Authorization
Your health insurance plan generally must cover emergency medical services without requiring advance approval, also known as prior authorization.
- Out-of-Network Emergency Services Must Be Covered
Your insurance plan must provide coverage for emergency services received from out-of-network providers, subject to applicable federal requirements.
- Your Cost-Sharing Amounts Must Be Calculated Appropriately
Your insurance plan must calculate your responsibility using the applicable in-network cost-sharing rules and clearly identify that amount on your Explanation of Benefits (EOB).
- Your Payments Must Count Toward Your In-Network Limits
Applicable cost-sharing payments for protected emergency and out-of-network services must count toward your in-network deductible and annual out-of-pocket maximum.
Questions or Concerns About Your Medical Bill?
At Buffalo Ambulatory Surgery Center, we believe patients should understand their financial responsibilities and the protections available to them.
If you have questions about your bill or believe you have been incorrectly charged, please contact our office.
Buffalo Ambulatory Surgery Center
Phone: 716-896-3815
You may also contact the federal No Surprises Help Desk for additional information or to file a complaint.
Federal No Surprises Help Desk
Phone: 1-800-985-3059
Website: https://www.cms.gov/nosurprises/consumers
For additional information about your rights and protections under federal law, please visit the website listed above.
This notice provides general information about your rights under the federal No Surprises Act. Additional protections may be available under applicable state laws and your health insurance coverage.