Medical Bill Negotiator
The No Surprises Act: Your Rights Against Balance Billing and Surprise Medical Bills
The No Surprises Act protects you from unexpected out-of-network bills. Learn exactly what it covers, how to dispute a surprise bill, and how to file a complaint when violated.
Before January 2022, Americans regularly received four-figure bills from anesthesiologists, radiologists, and other specialists they never chose — because those providers were out-of-network at in-network facilities. The No Surprises Act ended most of these practices. But knowing the law is only the first step — you have to actively enforce your rights when providers violate it.
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What the No Surprises Act Does (and Doesn't) Cover
What the NSA protects you from:
- Emergency care from any provider, at any facility: If you receive emergency care, you cannot be billed more than in-network cost-sharing (your deductible, copay, or coinsurance under your plan), regardless of whether the providers are in-network.
- Non-emergency care at in-network facilities from out-of-network providers: When you go to an in-network hospital for a scheduled procedure, you may unknowingly be treated by out-of-network anesthesiologists, radiologists, assistant surgeons, or hospitalists. Under the NSA, these providers must bill you at in-network rates.
- Air ambulance services from out-of-network providers: Emergency air ambulance services are covered under NSA protections.
What the NSA does NOT cover:
- Out-of-network care you deliberately chose (e.g., seeing an out-of-network specialist by choice)
- Ground ambulance services (these are specifically excluded)
- Care from out-of-network providers when you could have reasonably chosen in-network alternatives
The Surprise Bill Scenario: A Real Example
Here's the classic surprise billing scenario the NSA was designed to stop:
- You need a knee surgery. You find an in-network orthopedic surgeon and in-network hospital. You pay your deductible.
- During surgery, an anesthesiologist (who you never met, never selected, and had no ability to choose) administers anesthesia. That anesthesiologist's group has no contract with your insurer — they're out-of-network.
- Weeks later, you receive a bill from the anesthesia group for $4,800 — your 'out-of-network' share.
Under the NSA: This bill is illegal. The anesthesia group must bill your insurance at in-network rates and can only charge you in-network cost-sharing amounts. If they send you a bill for more, you can dispute it and they must refund any amount collected in violation of the law.
The law places the dispute between the provider and the insurer — not between you and the provider.
Consent Exception: When Providers Can Charge Out-of-Network Rates
There is one major exception to the NSA: if you voluntarily consent in writing to out-of-network care AND the provider discloses the estimated cost, they can bill at out-of-network rates.
Requirements for this exception:
- You must receive advance written notice of out-of-network status at least 72 hours before care (or same day for care scheduled less than 72 hours out)
- You must receive a good faith cost estimate
- You must sign written consent acknowledging you're waiving NSA protections
Red flags: If a provider gives you a form to sign at registration that mentions 'out-of-network charges' or 'consent to balance billing' — read it carefully. Signing that form voluntarily waives your NSA protections. You can often refuse to sign for anesthesiologists and other providers you didn't affirmatively choose.
Providers who cannot use the consent exception: Anesthesiologists, radiologists, pathologists, neonatologists, and other specialists in the same facility as your in-network surgeon typically cannot use this consent exception for non-emergency care. The NSA specifically limits this.
How to Dispute a Surprise Bill Under the NSA
If you received a bill that violates the No Surprises Act:
Step 1 — Contact your insurance company: Tell them you received a surprise bill from an out-of-network provider for care at an in-network facility (or for emergency care). They're required to apply in-network cost-sharing. Request an NSA violation review.
Step 2 — Contact the provider's billing department: Inform them in writing that the bill appears to violate the No Surprises Act. Reference the specific provision (29 CFR 800 for employer-sponsored plans; 45 CFR 149 for individual/small group ACA plans).
Step 3 — File a federal complaint: If the insurer or provider doesn't resolve it:
- For most health plans: file a complaint at cms.gov/nosurprises
- CMS has a federal investigative process and can take action against providers who repeatedly violate the NSA
Step 4 — State enforcement: Many states have their own surprise billing laws that may apply. State laws can provide additional remedies. Contact your state insurance commissioner.
Good Faith Cost Estimates: Your New Right
The NSA also gives uninsured and self-pay patients new rights to advance cost estimates.
For uninsured/self-pay patients: When you schedule a service, you have the right to request a 'good faith cost estimate' from the provider. The estimate must include:
- Items and services reasonably expected as part of your care
- Each provider's expected charges
- The estimated total
If your final bill exceeds the good faith estimate by more than $400, you can dispute the bill through the NSA's patient-provider dispute resolution process. An independent arbitrator can reduce the bill to the estimated amount.
Practical use: Before any major non-emergency procedure, request a good faith estimate in writing. This establishes a price benchmark and creates NSA dispute rights if the bill comes in much higher.
State vs. Federal NSA Protections
The federal No Surprises Act is a floor, not a ceiling. Many states had their own surprise billing laws before the federal law — and some are stronger.
States with strong pre-existing surprise billing protections: California, New York, Texas, Illinois, New Jersey. These states' laws may provide additional remedies, including state enforcement and private rights of action.
How the interplay works: The federal NSA applies to most employer-sponsored health plans (ERISA plans) and individual/small group ACA plans. State laws apply to state-regulated fully insured plans. Some plans are exempt from both (fully self-insured employer plans are ERISA-governed and exempt from state law).
If you're unsure which law applies to your situation, file complaints with both your state insurance commissioner and the federal CMS system. They'll sort out jurisdiction.
Frequently Asked Questions
Quick answers to the most common questions on this topic.
Does the No Surprises Act apply to ground ambulances?
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No. Ground ambulances were specifically excluded from the NSA. Ground ambulance balance billing remains a serious problem. Some states have their own protections; check your state's laws. Federal legislation to address ground ambulances has been proposed but not yet enacted.
What if I already paid a surprise bill — can I get a refund?
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If you paid a bill that violated the NSA, you may be able to recover the overpayment. Contact your insurance company, request they apply NSA protections retroactively, and file a complaint with CMS. The provider may be required to refund amounts collected in violation of the law.
Does the NSA apply to Medicaid or Medicare?
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The NSA applies primarily to commercial insurance (employer plans, ACA marketplace plans). Medicare and Medicaid have their own billing regulations that provide similar protections in different ways.
Can a provider bill me if I signed a consent to out-of-network billing?
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Depends on the situation. For emergency care and for providers you had no ability to choose (like anesthesiologists and radiologists at in-network facilities), the consent exception doesn't apply — even if they got you to sign something. For non-emergency care from a provider you chose voluntarily, consent may be valid.
Where do I file a complaint about a No Surprises Act violation?
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File at cms.gov/nosurprises. You can also file with your state insurance commissioner. CMS has established an investigative process and can sanction providers and insurers who violate the law.