Asking a provider to put its expected charges in writing before you book is an ordinary request, and when you are paying for care yourself, a federal rule backs it. The document is called a good faith estimate. Under that rule, part of the No Surprises Act, which took effect on January 1, 2022, providers usually have to give one to people who do not have health insurance or are not using it to pay for their care, when the care is booked at least 3 business days ahead or when the person asks. An estimate is not a contract and does not require you to get the care from any provider or facility it names. Ask for it before you book, read it for what the quoted price leaves out, such as care in later months, and keep it, because a bill that comes in well over it may be disputable.
Who the rule covers, with insurance or without
The rule reaches you if you have no health insurance, and it reaches you just the same if you have a plan and are choosing not to use it for this care. Either way, let the provider know in advance that you are not using insurance, which is also one of the conditions for disputing a bill later. You can ask the provider in plain words, since the specific term "good faith" is not needed to request an estimate. You will not get one during emergency care.
People may choose not to use insurance when the service they need is not covered, or when paying out of pocket is less expensive. When a lower price has you comparing medicine online, deep discounts and prices that appear too good to be true are among the signs that an online pharmacy may be unsafe (see Is a cheap injection from a private seller safe to buy?).
A business day here means a weekday. If you book care 3 to 9 business days ahead, the estimate is due within 1 business day, and if you book 10 or more business days ahead, it is due within 3 business days. Booking 0 to 2 business days ahead does not entitle you to one. You can also ask before you book anything, and the provider then has 3 business days to give it to you, so asking first lets you see the figures before you pick a date.
The law's billing protections have exceptions. Among them, ground ambulance services are generally not covered unless a state law has different rules, and services covered by short-term limited duration plans, health care sharing ministry plans or fixed indemnity plans, such as hospital indemnity insurance, fall outside the protections too. If you use Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care or TRICARE, those plans already protect you from some unexpected out-of-network bills. If you have one of these plans and are not sure whether the estimate rule reaches the care you are booking, call the No Surprises Help Desk at 1-800-985-3059, which answers questions about the No Surprises Act in English, Spanish and over 350 other languages.
What has to be on the estimate, and what may be missing from it
An estimate has to be an itemized list of the items and services related to your care, with specific details and an expected charge for each, given to you printed on paper or by email, whichever you prefer. Its charges should include facility fees, hospital fees, and room and board from the provider or facility that gives you the estimate. If you ask, the provider or facility can go through it with you over the phone or in person.
Each estimate currently lists the expected charges of a single provider or facility, even when several will be involved in your care, so ask every provider and the facility for their own. For a scheduled surgery, that means two requests, one to the surgeon and one to the hospital, and a further one to any other provider or facility whose care you will need.
Some charges might not appear on an estimate:
- items or services related to your care that are scheduled separately, such as appointments before surgery or physical therapy in the weeks after it
- items or services another provider or facility will give you
- additional items or services your doctor did not anticipate before giving the care
If your care repeats over several months, ask the provider whether the estimate covers the repeat visits, and for how long. An estimate written on the sample form that the federal government publishes for providers carries a line for recurring care, "The estimated costs are valid for 12 months from the date of the Good Faith Estimate." Providers are not required to use that form, so a line like it may not be on yours.
What you can do when the bill comes in higher than the estimate
When one provider's bill comes in higher than that provider's estimate, check the federal dispute page for the amount by which a bill must exceed its estimate before it can be disputed. If the bill is over by at least that amount, you may be able to dispute it through the federal patient-provider dispute resolution process, in which an independent third party reviews the bill and determines an appropriate payment. You can also call or write to the provider or facility that sent the bill: tell them the charges are higher than their estimate, and ask them to update the bill to match it, to negotiate it, or whether financial assistance is available.
You can dispute the bill only if all of these are true:
- when you got the care, you did not have health insurance or did not use it to pay for the care
- before the care, you told the provider you were not using insurance to pay for it
- you got the care on or after January 1, 2022
- you have a good faith estimate that you received from the provider or facility 3 days before the scheduled appointment
- your first bill is dated within the last 120 calendar days, about 4 months
- one of your providers or facilities charged more than its estimate by at least the amount the page sets
Count the 120 days from the date on the first bill, and start well inside them. To file, you need a digital or paper copy of the estimate and of the bill, the provider's contact information, and an administrative fee that is not refunded, in the amount the page lists. The process does not start until the fee is paid, and if the dispute is decided in your favor, the fee comes off what you owe the provider.
Start the dispute from the federal Dispute a medical bill page, either online, where you give an email address and request a one-time PIN, or by mail or fax with the form that page provides. With a mailed form, the fee is paid by money order or cashier's check, and cash and personal checks are not accepted. Send copies and keep your original documents.
Whatever the outcome, your costs will not increase because you disputed. If the reviewer finds you needed items or services your doctor could not reasonably have anticipated, the cost of your care is found appropriate and the bill stays as it is. If the reviewer finds instead that the provider or facility should have been able to tell you about those costs in advance, or that the unplanned services and supplies were not medically necessary, the provider must reduce the bill.
While the dispute is running, the provider or facility cannot:
- move the bill into collections, or threaten to
- collect any existing late fees on unpaid bills until the process ends
- take action against you because you are disputing
If the bill is already in collections, the provider or facility has to stop pursuing payment until the dispute is resolved. You and the provider can still settle on a payment amount before the process ends, whether that is a reduced bill or the full billed amount. If you settle, the provider must take at least half the fee off your bill and tell the independent reviewer that you have settled. If the dispute is decided in your favor and the provider keeps billing you or sends the bill to collections, submit a complaint to the No Surprises Help Desk, online or by phone at 1-800-985-3059.
If the provider never gave you an estimate
If you have booked care and no estimate has come, ask the provider for one in writing, because you cannot dispute a bill without an estimate. If you lose yours, ask the provider for a new copy. If you did not get one and think you should have, submit a complaint to the No Surprises Help Desk, online or by phone at 1-800-985-3059. In most cases the provider is required to give you an estimate before you get care. When you submit a complaint, you are still responsible for paying the bill.
What to do from booking to the last bill
- Before you book, tell the provider you are not using insurance, and ask each provider and the facility for an estimate in writing.
- Keep every estimate in a safe place, and take a picture of it with your phone if you have one.
- When a bill arrives, set it beside the estimate from the same provider and compare them line by line.
- If one provider's bill is over its estimate by at least the amount the dispute page sets, start the dispute well inside the 120 days.
An estimate is not a ceiling on the bill, and a bill that is over it by less than the amount the dispute page sets does not qualify for a dispute. For a gap below the page's amount, call or write to the provider or facility that sent the bill and ask them to update the bill to match the estimate, to negotiate it, or to tell you whether financial assistance is available.
