The No Surprises Act: Your Rights Against Unexpected Medical Bills

Balance billing happens when an out-of-network provider bills you for the difference between their charge and what your insurer paid. For example: an out-of-network anesthesiologist charges $4,000. Your insurer pays $1,200 (their allowed amount for out-of-network). The anesthesiologist then bills you for the $2,800 "balance." This is a surprise bill.

Surprise bills most often occur in emergency situations (where you have no ability to choose providers) and when out-of-network specialists are involved in care at an in-network hospital — like an anesthesiologist or radiologist you never chose or even met.

Effective January 1, 2022, the No Surprises Act (NSA) prohibits balance billing in two main scenarios. First, for emergency services at any hospital or emergency facility — even if the facility or the treating providers are out of network, you can only be billed in-network cost-sharing amounts. Second, for non-emergency care at in-network facilities when out-of-network providers are involved without your informed consent.

Under the NSA, if an out-of-network provider works at an in-network facility (like a hospital), they must inform you in advance and obtain your written consent before billing you at out-of-network rates. Without your written consent, they must accept in-network rates. You also have the right to request a list of in-network providers before a scheduled procedure.

The NSA also created the right to a Good Faith Estimate (GFE) for uninsured or self-pay patients. If you schedule a service at least three business days in advance, the provider must give you a written estimate of expected charges — including any associated services (anesthesia, lab work, etc.). This estimate must be given within one business day for appointments scheduled 10 or more days out.

If your final bill exceeds the Good Faith Estimate by more than $400, you have the right to dispute it through the NSA's Patient-Provider Dispute Resolution process. This process costs $25 to initiate and can result in the provider being required to accept the estimated amount.

The NSA has important limitations. It doesn't apply to ground ambulance services — a significant gap, as air and water ambulance are covered, but ground ambulance (the most common type) is not. Many states have separate laws covering ground ambulance, so check your state's rules.

The law also doesn't apply to out-of-network care at out-of-network facilities that you knowingly chose. If you decide to see an out-of-network specialist at their own office, or go to an out-of-network hospital for a non-emergency, balance billing protections don't apply. Coverage also varies for services received at certain provider-owned clinics, urgent care centers, and other facility types.

First, verify whether the NSA applies. Check whether the service was an emergency, or whether it was at an in-network facility. Then check whether you signed a consent form agreeing to out-of-network billing — read anything you signed at the facility carefully.

If you believe the bill violates the NSA, contact your insurer first — they're required to help resolve NSA disputes. You can also file a complaint with the federal No Surprises Help Desk at 1-800-985-3059 or at cms.gov/nosurprises. State insurance commissioners handle complaints for state-regulated plans. Document everything in writing.