Surprise Medical Bills: Still a Problem Despite Promises

The Limits of the No Surprises Act: A Growing Concern for Patients

Last year, Jessica Chen from Massachusetts faced an unexpected financial burden after undergoing a mammogram and sonogram at Lowell General Hospital-Saints Campus, part of Tufts Medicine. Before the procedure, she inquired about her out-of-pocket costs using her insurance, Tufts Health Plan, and was told she would pay $359. She paid that amount, only to be shocked weeks later when she received a bill for an additional $1,677.51. As a physician assistant, Chen found the situation both frustrating and confusing.

The No Surprises Act, enacted in 2022, was designed to protect individuals covered under group and individual health plans from receiving surprise medical bills. According to the Centers for Medicare & Medicaid Services (CMS), the law aims to shield patients from unexpected charges. However, despite this legislation, cases like Chen’s continue to occur.

With the help of her tech-savvy boyfriend, Chen discovered the hospital's "machine-readable" master price list and found that the negotiated rate between Lowell General and her insurer was $302.56 — significantly lower than what she had paid. She then filed a complaint with CMS, but the agency responded that the protections of the No Surprises Act did not apply in her case.

Tufts Medicine spokesperson Jeremy Lechan explained that healthcare billing is complex and involves multiple factors, which can lead to discrepancies between initial estimates and actual charges. While the No Surprises Act has been successful in addressing some unfair practices in medical billing, it does not cover all situations.

The law primarily protects patients from one specific type of surprise bill: when they receive out-of-network care at an in-network facility or are forced to get out-of-network care during an emergency. Before the law was passed, patients could face exorbitant bills that their insurance wouldn’t cover. However, the act currently provides protection only for uninsured and self-pay patients, leaving those with insurance vulnerable in certain scenarios.

Patients who qualify for protection under the No Surprises Act are entitled to an up-front, good-faith estimate for treatment scheduled at least three business days in advance. If a bill exceeds the estimate by more than $400, patients can dispute it. However, a key provision requiring a good-faith estimate of out-of-pocket costs for insured patients has yet to be implemented, as the government has not issued clear guidelines on its format.

Despite these efforts, many Americans still face unexpected medical bills that they could not have anticipated. Jessica Robbins, a product developer in Chicago, was recently billed $3,300 for a breast MRI she had two years earlier, even though she had prior authorization from her former insurer. She encountered difficulties resolving the issue, as the clinic where she had the procedure no longer existed.

Similarly, Mary Ann Bonita from Fresno, California, was surprised by a $1,039 bill for a chest X-ray she had paid for upfront at an emergency room. Her husband described the lack of explanation as perplexing and concerning.

Zack Cooper, an associate professor of economics at Yale University, noted that while the No Surprises Act addresses a specific type of charge, other billing issues remain unresolved. His research found that before the law was passed, over 25% of emergency room visits resulted in surprise out-of-network bills. CMS has received thousands of complaints, and while some practices are not regulated by the law, these trends highlight the need for further improvements.

Michelle Rodio, a teacher in Lakewood, Ohio, was also caught off guard by a $2,700 bill after a nasal swab at Cleveland Clinic. Despite her shock, the provider stated the bill was not a “surprise bill” under current law. This highlights the gap in protections for patients with insurance, as the relevant provisions of the No Surprises Act have not yet been fully implemented.

As these cases demonstrate, the No Surprises Act has made progress in addressing some of the most egregious billing practices, but there is still much work to be done to ensure that all patients are protected from unexpected and unanticipated medical expenses.