No Surprise Billing Statement
Purpose
This policy outlines the rights of patients and the responsibilities of this practice under federal and state laws designed to protect patients from surprise medical bills, also known as balance billing.
Policy Statement
Our practice complies with the federal No Surprises Act (effective January 1, 2022) and applicable Florida laws to protect patients from unexpected charges for out-of-network care in certain situations.
Scope
This policy applies to all providers, staff, and patients receiving medical services from this practice, including both in-person and telehealth visits.
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1. What is Surprise (Balance) Billing?
“Surprise billing” occurs when a patient receives an unexpected bill for the difference between what their insurance plan pays and what an out-of-network provider charges—often without the patient’s knowledge or consent.
Under the law, patients cannot be balance billed for:
Emergency services, even if provided by an out-of-network provider or facility.
Certain non-emergency services provided by an out-of-network provider at an in-network hospital or ambulatory surgical center, unless the patient provides prior written consent.
Air ambulance services provided by out-of-network providers.
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2. Patient Protections
Patients are protected from surprise bills in the following ways:
They only pay their in-network cost-sharing amounts (like copayments, coinsurance, and deductibles).
These payments must count toward the patient’s in-network deductible and out-of-pocket maximum.
The provider and insurance company will work together to resolve any payment differences.
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3. Notice and Consent Requirements
If a patient chooses to receive non-emergency out-of-network services at an in-network facility, they may voluntarily consent to pay out-of-network rates—but only after receiving:
A written notice at least 72 hours before the service (or as soon as practicable for same-day services).
A good faith estimate of charges.
A consent form that meets federal and Florida requirements.
Patients are not required to sign this consent and may decline out-of-network care.
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4. Florida-Specific Protections
Under Florida law (Fla. Stat. §627.64194 and §641.513):
Balance billing is prohibited for emergency services and covered non-emergency services when provided at an in-network facility.
Providers must bill the insurance plan directly, not the patient, for covered services.
Patients are responsible only for applicable copayments, coinsurance, and deductibles under their plan.
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5. Good Faith Estimates (For Uninsured or Self-Pay Patients)
Uninsured or self-pay patients have the right to receive a Good Faith Estimate (GFE) of expected charges before receiving services.
The GFE will include itemized charges for medical, facility, laboratory, or other services that may be reasonably expected.
If the actual bill is $400 or more higher than the estimate, patients may dispute the bill through the Health and Human Services (HHS) dispute resolution process.
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6. Patient Rights and Dispute Process
Patients who believe they’ve been wrongly billed can:
Contact the Florida Department of Financial Services (DFS) Consumer Helpline: 1-877-MY-FL-CFO (1-877-693-5236).
Contact the U.S. Department of Health & Human Services: 1-800-985-3059 or visit
cms.gov/nosurprises.
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7. Compliance and Enforcement
Our practice will:
Post the No Surprises Act notice on our website and in our office.
Provide written notice to patients regarding their rights.
Maintain records of Good Faith Estimates and consent forms for at least 6 years.
Train staff to ensure compliance with all requirements.
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8. References
No Surprises Act, Title I, Division BB of the Consolidated Appropriations Act, 2021
45 CFR §149.410 – §149.460 (Federal regulations)
Florida Statutes §627.64194 and §641.513
CMS No Surprises Act Guidance (
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Legal Protections in Florida
There are two layers of protections: federal (the No Surprises Act) and Florida state law. They overlap but there are some differences.
Federal: No Surprises Act (effective Jan 1 2022)
Under the federal law, when you receive emergency services from an out-of‐network provider or facility, or you are treated by an out-of-network provider at an in-network facility (without your knowing), you can only be charged the same cost-sharing (copay, coinsurance, deductible) as if the provider were in-network.
For uninsured or self-pay patients, providers must give a “Good Faith Estimate” of cost in advance in many cases.
Florida State Law
Florida law adds extra protections (for certain plans) and places specific obligations on providers/facilities. Some of the highlights:
Florida law prohibits surprise billing in emergency situations (all types of plans) when you are treated by an out-of-network provider/facility.
If you are in an in-network hospital or ambulatory surgical center (ASC) and a provider (e.g., anesthesiologist, radiologist, pathologist) who treats you is out-of-network and you did not choose them knowingly, you are protected — the most you should be required to pay is your in-network cost-sharing.
Hospitals in Florida must post on their websites the health plans with which they participate (i.e., are in-network) and must notify that you may be treated by out-of-network practitioners in their facility.
For certain Florida-licensed HMOs and for some PPO/EPO plans, Florida law prohibits balance billing (non-emergency) when the patient has no meaningful ability to choose a participating provider.
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What you pay (and what you don’t)
If you receive emergency care (or certain other covered situations), you pay only what you would have paid if the provider/facility were in-network — i.e., your normal copay / coinsurance / deductible for an in-network service. The out-of-network provider/facility cannot bill you for more.
Your health plan must count any cost-sharing you pay toward your in-network deductible and out-of-pocket maximum.
If you are uninsured or paying out-of-pocket, you have the right to a Good Faith Estimate of costs; if your bill ends up being much higher than the estimate (e.g., $400+ difference in some cases), you can dispute it.
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What to watch out for / limitations
Self-funded employer plans: Some protections under Florida state law may not apply to self-funded employer health plans (which are regulated under federal ERISA law) — the federal law still applies though.
For non-emergency services in an in-network facility: If you knowingly consent to be treated by an out-of-network provider (after disclosure), you may sign away some protections. Florida law requires written consent in some cases.
Not all out-of-network situations are fully protected: Some providers like labs, pathology, etc., may still bill you if you signed a waiver or consent to out-of-network services.
You should proactively check whether the specialist providers (anesthesiologists, radiologists, lab/pathology) are in-network, especially when scheduling elective/non-emergency services. Florida law requires hospitals to post info, but you still need to review.
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What to do if you believe you got a surprise bill in Florida
1. Review your Explanation of Benefits (EOB) from your insurer: check whether the provider/facility was treated as in-network or out-of-network.
2. Contact your health plan and ask: “I believe I received services at an in-network facility but was treated by an out-of-network provider I didn’t choose. Am I protected under Florida law and/or the No Surprises Act?”
3. Contact the provider/facility billing department: ask why you’re being billed for out-of-network charges when you believed you were using an in-network facility.
4. If applicable, you can file a complaint:
Florida’s Agency for Health Care Administration: 1-888-419-3456
U.S. Department of Health & Human Services No Surprises Help Desk: 1-800-985-3059
5. If you signed a “surprise billing protection form” (waiver) before the service, check the timing and adequacy of disclosure—Florida law has rules about written consent and time frames.
USave Health
Practice/Company Name: USave Health
Primary Business Address: 2630 W Broward Blvd Suite 203-1842, Fort Lauderdale, FL 33312-1314
Phone: 954-870-4790
Email: policy@usavehealth.com
Website: usavehealth.com
Effective Date: [10/1/2025]
Last Updated: [10/1/2025]