The No Surprises Act: What Patients Need to Know

The No Surprises Act targets the specific scenarios where patients historically had no control over whether their provider was in-network. The law covers three core situations:

• —Emergency services: All emergency care must be billed at in-network rates, regardless of which facility or provider treats you. You do not need to check network status during an emergency — that is the entire point.
• —Out-of-network providers at in-network facilities: If you go to an in-network hospital and are treated by an out-of-network doctor (a common scenario with anesthesiologists, radiologists, pathologists, and ER physicians), you cannot be billed more than in-network cost-sharing amounts.
• —Air ambulance services: Out-of-network air ambulance providers cannot balance bill you beyond in-network cost-sharing amounts.

In all these cases, the provider and your insurer must work out the payment between themselves. You only owe your in-network copay, coinsurance, or deductible.

The No Surprises Act protects patients covered by most types of health insurance, including employer-sponsored plans, individual marketplace plans, and federal employee plans. It applies to both fully insured and self-insured group health plans. The protections are automatic — you do not need to sign up, request coverage, or take any action to be protected. If you have insurance and receive care in one of the covered scenarios, the law applies. For uninsured and self-pay patients, the Act provides related but different protections through the Good Faith Estimate requirement, which gives you the right to a cost estimate before scheduled services and the right to dispute bills that exceed the estimate by $400 or more ³.

The emergency care provisions are the strongest and most straightforward part of the law. When you go to an emergency room — whether the hospital is in-network or out-of-network — you are protected from balance billing for the entire emergency visit. This includes the facility fee, all physician charges, and all ancillary services (labs, imaging, medications) provided during the emergency. The protection extends through the point of stabilization — meaning all care from the moment you arrive until your condition is stabilized. If you are admitted to the hospital after stabilization and the hospital is out-of-network, the facility must give you notice and obtain your consent before billing at out-of-network rates for post-stabilization care. Without that notice and consent, the in-network billing protection continues.

If you receive a bill that you believe violates the No Surprises Act, you have clear steps to take:

• —Contact your insurer first — explain that you believe the bill violates surprise billing protections and ask them to reprocess it at in-network rates
• —Contact the provider's billing department — inform them that the charge is subject to the No Surprises Act and should be adjusted to in-network cost-sharing only
• —File a complaint with CMS at 1-800-985-3059 or through the No Surprises Help Desk if the provider or insurer does not comply
• —Request Independent Dispute Resolution (IDR) ² if you are an uninsured or self-pay patient whose bill exceeds your Good Faith Estimate by $400+ ³

Providers face penalties of up to $10,000 per violation ¹ for billing patients in excess of what the No Surprises Act allows. Mentioning this in your communications can be effective.

The No Surprises Act created a new Independent Dispute Resolution (IDR) process to resolve payment disputes between providers and insurers ². Here is how it works in practice: when a provider and insurer cannot agree on an out-of-network payment amount, either party can initiate IDR. A certified third-party arbitrator reviews both sides' proposed payment amounts and selects one — this is a "baseball-style" arbitration where the arbitrator must pick one side's number, not split the difference. The arbitrator considers the qualifying payment amount (QPA) — typically the insurer's median in-network rate — along with factors like the provider's training, the complexity of the case, and local market rates. Critically, the patient is not involved in this process and is not responsible for any amount beyond their in-network cost-sharing, regardless of the arbitration outcome.

While the law is comprehensive, it has important gaps:

• —Ground ambulances are not covered — only air ambulances are included. Ground ambulance balance billing remains a significant gap, though some states have their own protections.
• —Non-emergency care where you consent to out-of-network treatment — if a provider gives you written notice at least 72 hours before scheduled care that they are out-of-network, and you sign a consent form, you waive your surprise billing protections for that provider.
• —Short-term and limited benefit insurance plans may not be covered under the federal law, though state laws may provide protection.
• —Bills that are high but not "surprise" bills — if your in-network hospital charges you $50,000 for a procedure and that is the correct in-network rate, the No Surprises Act does not apply. The law addresses network status, not price fairness.

For high but technically correct bills, your best option is to upload the bill to ORVO, compare against market rates, and negotiate based on the data.

Many states enacted their own surprise billing laws before the federal No Surprises Act, and some go further than the federal law. States like New York, California, Texas, Florida, and Colorado have additional protections that may cover scenarios the federal law does not — including ground ambulance billing, broader definitions of emergency care, and stricter penalties for violations. When both state and federal laws apply, the stronger protection generally prevails for the patient. If you are disputing a surprise bill, check whether your state has its own surprise billing law in addition to the federal protections. Your state insurance commissioner's office can clarify which rules apply to your specific situation.

Even with the No Surprises Act in place, proactive patients get better outcomes. Here is how to minimize your exposure to billing surprises:

• —Always ask whether every provider involved in your care is in-network — not just the primary surgeon or facility, but anesthesiologists, assistants, labs, and imaging centers
• —Never sign a consent to waive your surprise billing protections unless you fully understand the cost implications and have no alternative
• —Request a Good Faith Estimate for any scheduled procedure, especially if you are uninsured
• —Review every bill carefully — the No Surprises Act protections only help if you know to invoke them. A bill that violates the law looks like any other bill until you challenge it.
• —Upload your bills to ORVO to compare charges against fair market rates and identify whether the No Surprises Act or direct negotiation is your best path to a fair price
• —Save all documentation — estimates, consent forms, EOBs, and correspondence — for at least one year after each medical encounter