Federal law enacted in 2022 bans the most common types of surprise medical bills. Here's exactly what's covered, how to dispute violations, and what to do if a provider tries to charge you anyway.
The No Surprises Act (NSA) is a federal law that took effect on January 1, 2022. It protects patients from unexpected, high medical bills in specific situations where you have limited control over which provider you see.
If you receive emergency care, or if an out-of-network provider treats you at an in-network facility without your consent, you can only be charged your in-network cost-sharing amount (your normal deductible, copay, and coinsurance). The provider cannot bill you for the difference between what they charge and what your insurance pays.
No matter where you receive emergency care — even at an out-of-network ER — you can only be charged in-network cost-sharing amounts. Insurers must cover emergency services without prior authorization.
If you go to an in-network hospital or facility and an out-of-network provider treats you (like an anesthesiologist or radiologist you didn't choose), you can only be charged your in-network rates.
Air ambulance services provided by out-of-network carriers are covered at in-network cost-sharing rates for patients with private insurance. This is a major protection given air ambulance bills can exceed $50,000.
Uninsured and self-pay patients must receive a Good Faith Estimate before scheduled care. Insured patients who request one must also receive it. If your final bill exceeds the estimate by $400+, you have the right to dispute it.
The law has important gaps. It does not apply to:
The law applies in three main situations. Understanding exactly when you're covered helps you know when to push back on a bill.
Any emergency medical condition treated at any emergency department — in-network or out-of-network — is covered. This includes the facility charges, physician charges, and any providers involved in your stabilization care.
If you schedule a procedure at an in-network facility and an out-of-network specialist is involved (without your advance written consent), you're protected. Classic example: your surgeon is in-network but the anesthesiologist is not.
Out-of-network air ambulance services are covered under NSA protections. Bills from air ambulance companies are some of the most devastating surprise bills — averaging over $28,000 per flight.
If you're uninsured or paying out of pocket, providers must give you a written Good Faith Estimate before scheduled services. This applies to non-emergency care when you request it or when you have a scheduled appointment.
| Situation | NSA Coverage |
|---|---|
| Emergency care at any ER (in or out-of-network) | ✓ Covered |
| Out-of-network anesthesiologist at in-network hospital | ✓ Covered |
| Out-of-network radiologist reading your in-network scan | ✓ Covered |
| Out-of-network air ambulance (private insurance) | ✓ Covered |
| Out-of-network provider you chose and signed consent for | ✗ NOT covered |
| Ground ambulance (private or public) | ✗ NOT covered |
| Fully out-of-network care (you went to OON doctor by choice) | ✗ NOT covered |
| Medicare or Medicaid plans | ✗ NOT covered |
A Good Faith Estimate (GFE) is a written document that lists expected charges for a scheduled healthcare service. It's one of the strongest tools the NSA gives patients — and most people don't know it exists.
Every expected item, service, and supply — with diagnosis codes, procedure codes, expected charges, and the expected amount you'll owe after insurance.
Name, address, NPI number, and TIN of each provider or facility expected to be involved in your care — including specialists like anesthesiologists.
The expected billed charge and your expected out-of-pocket cost. This is the number that matters — if your final bill exceeds it by $400+, you can dispute it.
Call or email the billing department and say: "I'm requesting a Good Faith Estimate under the No Surprises Act before my scheduled appointment."
Ask them to include all expected providers — including the facility, your primary physician, any specialists who may be involved (anesthesiologist, radiologist, etc.), and any labs.
Document everything: the name of the person you spoke with, the date, and what was said.
If the provider refuses or fails to provide a GFE in time, that's a violation you can report to CMS (see Section 8).
Save the GFE in a safe place. When your bill arrives, compare each line item against the GFE. Flag any discrepancies immediately.
Check that every provider who treated you is listed. If an unlisted provider bills you separately, that could also be a violation worth disputing.
Important: A GFE is not a final bill — actual costs can vary due to unforeseen medical circumstances. But if the difference is $400 or more without a legitimate medical reason, you have the right to dispute it.
If your final bill is $400 or more above your Good Faith Estimate, you have the right to initiate a Patient-Provider Dispute Resolution (PPDR) process. Here's how to fight it step by step.
You can initiate a dispute if your bill is $400 or more higher than your Good Faith Estimate. You must file the dispute within 120 calendar days of receiving your bill. Act promptly — missing this deadline forfeits your right.
You need three key documents:
Before filing a formal dispute, call or write to the provider's billing department. Reference your GFE and explain the discrepancy. Many billing errors get resolved at this stage because providers know a formal dispute is a bigger headache for them too.
Keep a written record of every conversation — date, time, person's name, what was said. If they agree to adjust the bill, get it in writing.
Do not pay the disputed amount while the dispute is ongoing. Paying signals acceptance of the bill.
If informal resolution fails, file a formal dispute through the federal dispute resolution process:
The SDR entity will determine a reasonable payment amount. The provider must accept this decision — it's binding.
Cost: There is a small administrative fee (currently $25) to use the federal dispute resolution process. This is waived if the SDR rules in your favor.
While your dispute is in progress:
Balance billing is when a provider bills you for the difference between what your insurance paid and the provider's full charge. The NSA bans this in certain situations — but the exceptions matter.
Out-of-network providers in covered situations cannot:
The NSA allows out-of-network providers to balance bill you if they give you proper written notice AND you voluntarily sign a consent form before receiving care. This exception only applies to:
Critical: You must receive notice at least 72 hours before scheduled care (or 3 hours before same-day care). The notice must list the estimated charges, the in-network alternative, and your right to choose an in-network provider. If you didn't receive proper notice and still got a balance bill, that's a violation — dispute it.
Ask every provider involved in your care: "Are you in-network with my insurance plan?" Get the answer in writing. Don't assume — anesthesiologists and radiologists are frequently out-of-network even at in-network hospitals.
Read it carefully. If it's a consent to receive balance billing from an out-of-network provider, you have the right to refuse and request an in-network alternative. Don't sign under pressure — you have time to consider.
Don't pay it without verifying it's legitimate. Check whether you signed a consent form, whether the service was emergency care, and whether the provider is claiming NSA exemption correctly. Most illegal balance bills get dropped when challenged.
Call the provider and say: "I believe this bill violates the No Surprises Act. This was [emergency care / an out-of-network provider at an in-network facility]. I am disputing this balance bill and will file a complaint with CMS if not corrected."
The IDR process is how providers and insurers resolve payment disputes — not patients. But understanding it helps you know what happens behind the scenes and what your rights are when it affects your care.
There are two separate dispute systems under the NSA:
After a claim is processed, the provider and insurer have 30 business days to negotiate payment directly. During this period, the insurer must pay at least the Qualifying Payment Amount (QPA) — typically the median in-network rate for that service in your area.
If they reach agreement, the dispute ends. You're not affected — you only owe your in-network cost-sharing.
If negotiations fail, either party can initiate IDR within 4 business days. They must jointly select a certified IDR entity (arbitrator) within 3 business days, or use a CMS-assigned entity if they can't agree.
Both parties submit their final payment offers. The IDR entity reviews both and must pick one offer (similar to baseball arbitration — no splitting the difference). The entity considers:
The losing party pays the IDR administrative fee. You still only owe your in-network cost-sharing amount — the IDR outcome doesn't change what you owe.
If your insurer and provider are in IDR dispute, your job is simple: only pay your in-network cost-sharing amount. Do not pay the provider's full billed amount. If the provider threatens to send your balance to collections during an IDR dispute, that's a violation. Report it to CMS immediately.
Many states had surprise billing laws before the NSA. The good news: if your state law is stronger than federal law, you get the stronger protection. Here's how it works.
The NSA sets a federal floor — a minimum level of protection. States can offer additional protections, and those stronger state laws apply to fully insured plans (plans regulated by your state). But self-funded employer plans (most large company insurance) are federally regulated under ERISA and only subject to federal NSA rules.
| Plan Type | Which Law Applies | Who Regulates |
|---|---|---|
| Individual market (marketplace) plans | NSA + stronger state law | State insurance department |
| Small fully-insured employer plans | NSA + stronger state law | State insurance department |
| Large self-funded employer plans | Federal NSA only | CMS / federal government |
| Medicare Advantage | Medicare rules (separate protections) | CMS |
| Medicaid managed care | Medicaid rules (separate protections) | State Medicaid agency |
One of the strongest state laws — applies to all fully insured plans. Covers emergency and non-emergency OON situations. Dispute process available for bills over $650.
AB 72 prohibits balance billing from OON providers at in-network facilities. Applies to all state-regulated plans. Ground ambulance protections are among the broadest in the country.
State mediation process available for bills over $500 from OON providers. Applies before NSA (predates federal law). Fully insured plans get both state and federal protections.
All have comprehensive surprise billing laws that work alongside the NSA. State regulators actively enforce these rules and run consumer assistance programs.
Check your Summary of Benefits and Coverage (SBC) — it will say whether your plan is "fully insured" or "self-funded/self-insured." If it says "This plan is not an insurance policy. It is a self-funded group health plan," federal NSA rules apply exclusively. Contact your HR department or call your state insurance department if you're unsure.
If a provider or insurer violates the No Surprises Act, you have multiple channels to report the violation. Filing complaints isn't just about your case — it creates a regulatory record and can lead to investigations and fines.
The primary federal enforcer of the NSA. File at cms.gov/nosurprises or call 1-800-985-3059. CMS can investigate violations and impose civil monetary penalties of up to $10,000 per violation on providers and facilities.
For fully insured plans, your state regulator also has authority. Search "[Your State] Department of Insurance complaint" to find the online form. State agencies often have faster response times and additional consumer protections.
If you have employer-sponsored insurance (self-funded), your HR department or plan administrator is responsible for enforcing federal rules. File a written complaint with them — they have legal obligations to respond.
If an illegal balance bill was sent to collections or affected your credit report, file a complaint with the CFPB at consumerfinance.gov/complaint. They handle debt collection violations and credit reporting issues related to medical bills.
CMS has received hundreds of thousands of NSA complaints since 2022. Providers and insurers found in violation face fines and corrective action plans. When you file a complaint, you're not just helping yourself — you're protecting every patient who comes after you. And many providers quietly correct illegal bills the moment a complaint is filed.
Abstract law becomes clearer with real examples. Here's how the No Surprises Act plays out in the situations most patients actually face.
What happened: Maria had a car accident and was taken by ambulance to the nearest ER, which was out-of-network. After two days, she received a bill for $18,000 — her insurer paid $3,200 (the in-network rate), and the hospital billed her the $14,800 difference.
What the law says: This is a textbook NSA violation. Emergency care at any facility — in or out of network — must be billed at in-network cost-sharing rates. Maria only owes her deductible and coinsurance (approximately $400 in her case).
What happened: David scheduled knee surgery at his in-network hospital with an in-network orthopedic surgeon. He never met the anesthesiologist beforehand. Three weeks later, an anesthesiology group sent him a bill for $3,600 that his insurance wouldn't cover — they weren't in-network.
What the law says: David did not choose the anesthesiologist and did not sign a consent form authorizing out-of-network billing. The NSA protects him — he owes only his in-network cost-sharing for the anesthesia.
What happened: Sarah was uninsured and scheduled a colonoscopy. The gastroenterologist gave her a Good Faith Estimate of $1,200. When the bill arrived, it was $3,000 — $1,800 more than estimated. No medical complications occurred.
What the law says: The $1,800 discrepancy far exceeds the $400 dispute threshold. Sarah has 120 days from the bill to initiate a Patient-Provider Dispute Resolution through CMS.
What happened: James was airlifted from a remote camping accident. The air ambulance company billed $52,000. His insurance paid $9,000. The company sent him a balance bill for $43,000.
What the law says: The NSA covers air ambulance services for patients with private insurance. James can only be charged his in-network cost-sharing — approximately $1,000 in this case.
Ground ambulance bills are one of the most common sources of medical billing complaints — and the NSA does not currently cover them. A federal advisory committee submitted recommendations to Congress in 2024, and legislation is pending. Until ground ambulances are covered federally, check whether your state has specific protections. California, Texas, and several other states have enacted ground ambulance balance billing limits.
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