The Federal No Surprises Act Explained: What New York and New Jersey Patients Need to Know

Understanding the Federal No Surprises Act

Unexpected medical bills have caused stress and financial hardship for many patients. Many people believed they received covered, in-network care only to receive large bills later.

To address this problem, Congress passed the Federal No Surprises Act. This law protects patients from surprise medical billing in specific situations. Understanding these protections can help patients avoid paying medical bills they may not legally owe.

This article explains how the law works, what it covers, and when patients may need legal help.

What Is the Federal No Surprises Act?

The Federal No Surprises Act took effect on January 1, 2022. It protects patients from unexpected out-of-network medical bills when they have little or no control over the providers involved in their care.

Before the law took effect, patients often received surprise bills after emergency treatment or procedures performed at in-network hospitals by out-of-network physicians. Providers frequently billed patients for the difference between what insurers paid and what providers charged.

The No Surprises Act prevents this practice. Instead of involving patients in payment disputes, the law places responsibility on insurers and healthcare providers.

Why Congress Passed the No Surprises Act

Surprise medical billing became a national problem as more healthcare systems relied on out-of-network specialists who worked inside in-network facilities.

Even patients who carefully selected their insurance plans and hospitals sometimes received bills from providers they never chose and often never met.

Congress recognized that patients cannot compare providers during emergencies or complex medical procedures. Lawmakers passed the Federal No Surprises Act to create a fairer billing process and protect consumers from unexpected costs.

Medical Services Covered by the No Surprises Act

The law protects patients in several common situations that historically resulted in surprise bills.

Emergency Medical Care

The Act protects patients who receive emergency medical services. These protections apply even when the hospital or treating physicians are outside the patient’s insurance network. The law also covers post-stabilization care in many situations.

Non-Emergency Care at In-Network Facilities

The Act also protects patients who receive care at in-network hospitals, surgical centers, or similar facilities when out-of-network providers participate in treatment.

Common examples include:

• Anesthesiology
• Radiology
• Pathology
• Emergency medicine
• Hospital-based physician services

Patients generally cannot choose these providers. As a result, the law prohibits balance billing in most of these situations.

Air Ambulance Services

Before the Act, air ambulance bills often created significant financial burdens. The law now limits what patients must pay for out-of-network air ambulance services.

How the Law Applies in New York and New Jersey

New York and New Jersey enacted surprise billing protections before the federal law became effective.

Today, patients may receive protection under state law, federal law, or both. The applicable law often depends on the type of health insurance plan involved.

Because the interaction between state and federal laws can be complex, many patients struggle to determine which protections apply to their situation.

What Patients Must Pay Under the Act

When the Federal No Surprises Act applies, patients generally pay only the amount they would have owed for in-network care.

These costs may include:

• Copayments
• Coinsurance
• Deductibles

Providers cannot charge patients for the remaining balance between the provider’s charges and the insurer’s payment.

This prohibited practice is known as balance billing.

Common Misunderstandings About the Law

Many patients misunderstand the scope of the No Surprises Act.

Some people believe the law eliminates all out-of-network billing. It does not.

Others believe providers can easily avoid the law by obtaining signed consent forms. In reality, the law imposes strict notice and consent requirements, and providers do not always satisfy them.

These misunderstandings can cause patients to pay bills they do not legally owe.

Situations Where the No Surprises Act May Not Apply

In some circumstances, providers may charge out-of-network rates if patients voluntarily agree to receive out-of-network care.

However, providers must satisfy detailed notice and consent requirements. These rules govern timing, format, and required disclosures.

A signed form does not automatically make a bill lawful. If providers fail to follow the law’s requirements, patients may still have grounds to challenge the charges.

What to Do If You Receive a Surprise Medical Bill

Patients who receive a questionable medical bill should act quickly.

Important steps include:

• Review the bill carefully.
• Compare the bill with the insurance explanation of benefits.
• Keep copies of all records and correspondence.
• Avoid paying disputed charges before determining whether the bill is valid.

Patients may need professional guidance when providers or insurers refuse to correct improper charges.

When Legal Assistance May Be Necessary

Medical billing disputes often involve hospitals, physician groups, insurance companies, and third-party billing services.

When these parties fail to comply with the Federal No Surprises Act, patients may need legal assistance. An attorney can help determine which laws apply, challenge improper charges, and pursue available remedies.

For patients in New York and New Jersey, experienced healthcare counsel can help ensure that both federal and state protections are properly enforced.

Frequently Asked Questions

Does the Federal No Surprises Act apply to all insured patients?

The law primarily applies to insured patients, although the specific protections depend on the type of health plan involved.

Does the law eliminate all medical billing disputes?

No. The law protects patients from becoming involved in many payment disputes, but insurers and providers may still dispute reimbursement amounts.

Can doctors require patients to waive their rights?

Only in limited situations and only when they comply with strict notice and consent requirements.

Is the law automatically enforced?

Not always. Patients sometimes need to assert their rights or seek assistance to ensure compliance.

Can an attorney help with surprise billing issues?

Yes. Legal counsel can evaluate whether a bill violates applicable laws and assist with enforcement efforts.

Conclusion

The Federal No Surprises Act provides important protections for patients in New York and New Jersey. However, patients must understand their rights to benefit fully from those protections.

Surprise medical billing still occurs, and violations continue despite the law. Patients who recognize improper billing practices and seek help when necessary are in a stronger position to avoid unlawful charges and protect their financial interests.

Mitchell C. Beinhaker, Esq. is a business lawyer and estates attorney who runs a solo legal & consulting practice representing business owners, entrepreneurs, executives, and professionals. Through his 30+ years of experience, Mitchell has handled business development, marketing, firm management, along with business transactional work for clients of the firm. He has extensive experience with corporate governance, commercial transactions, real estate, and risk analysis. Using his years of practical experience, he drafts contracts, negotiates purchases, and can manage outside counsel for any corporate situation. For business owners and executives, he creates and implements estate plans, along with succession plans to help companies continue for future generations.  

Mitchell is the co-author of 10 Ways to Get Sued by Anyone & Everyone:  the small business owners guide to staying out of court, available in paperback and kindle from Amazon.

He is also the host of The Accidental Entrepreneur Podcast, available on YouTube, Amazon, Spotify, Apple and most of the other podcast directories.  You can find audio episodes posted on mitchbeinhaker.com and even purchase merchandise to support the show.

If you need legal help with any of our services, contact our office for a free consultation.  You can email us at info@beinhakerlaw.com.  To learn more about Mitchell and his practice, visit beinhakerlaw.com.