The No Surprises Act Passed. Surprise Bills Didn't Go Away.
The No Surprises Act Passed. Surprise Bills Didn't Go Away.
The No Surprises Act took effect on January 1, 2022, with a clear goal: protect patients from unexpected medical bills when they receive care from out-of-network providers in situations they could not have anticipated or avoided.¹ It was a significant piece of legislation. Patient advocates had fought for years to close the gap where patients were hit with large bills from providers they never chose and did not know were out-of-network.
Two years later, patients are still receiving surprise bills. Some of those bills are illegal under the law. Others are not, because of genuine gaps in what the law covers. And some fall into a gray zone where providers are using workarounds that regulators are still catching up to.
Understanding where you fall helps you know whether to pay, dispute, or file a complaint.
What the No Surprises Act Actually Covers
The law applies in specific, defined circumstances. Getting these right matters, because the law's protections only kick in when the covered situation applies to you.
Emergency services. If you go to an emergency department at an out-of-network hospital, or if you receive emergency services from an out-of-network provider at an in-network facility, the law limits your cost sharing to what you would have paid in-network.¹ You cannot be billed by the provider beyond your in-network cost share. The provider must bill your insurer directly and resolve any payment dispute through arbitration, not your wallet.
Non-emergency services at in-network facilities from out-of-network providers. This is the situation that generated the most notorious surprise bills before the law passed. You schedule a procedure at an in-network hospital. Your surgeon is in-network. But the anesthesiologist, the radiologist, or the assistant surgeon is out-of-network, and you had no way to know or choose otherwise. The No Surprises Act prohibits those providers from billing you above in-network cost sharing in most circumstances.¹
Air ambulance services. Out-of-network air ambulance providers are now prohibited from billing patients above in-network cost sharing for covered services.¹ Ground ambulance services are notably not included, which is one of the significant gaps discussed below.
Where the Law Doesn't Apply
The law has real boundaries, and these are the situations where patients often discover the protection they expected isn't there.
Ground ambulance services. If you are transported by a ground ambulance operated by an out-of-network provider, the No Surprises Act does not protect you.¹ Ground ambulance surprise billing remains legal under federal law. Some states have passed their own ground ambulance protections, but many have not. This is one of the most frequently cited gaps in the law's coverage.
Scheduled out-of-network services you consented to. The law includes a consent exception: if a provider is out-of-network for a non-emergency service and you give signed consent acknowledging the out-of-network status and the estimated cost, the provider can bill you at out-of-network rates.¹ This consent provision was intended for planned, non-emergency services where you genuinely choose an out-of-network provider. In practice, some providers have used it in situations where the choice was not truly voluntary.
Providers in facilities that are entirely out-of-network. If you choose to go to an out-of-network facility for a non-emergency service, the full range of the law's protections does not apply. The law was designed for situations where the facility is in-network but a provider within it is not.
Dental and vision services. The No Surprises Act applies to medical services covered under your health plan. Dental and vision plans are generally not subject to the same requirements.
Services not covered by your plan at all. If your insurer denies the underlying claim and the service is excluded from your plan, the surprise billing protections do not convert an excluded service into a covered one.
The Provider Workarounds
Even within the law's covered situations, some providers have found ways to generate bills that patients receive and sometimes pay, even when they shouldn't.
Consent form overuse. The consent exception described above is supposed to apply in limited circumstances where a patient voluntarily chooses an out-of-network provider for non-emergency services when an in-network alternative is available. Some providers have begun presenting broad consent forms to patients at check-in, including in situations where the patient is in an emergency or has no realistic choice. Federal regulations specify when consent is not valid (including in emergency situations and in situations where there is no in-network alternative at the facility), but enforcement of those limitations has been inconsistent.²
Balance billing for facility fees. Some health systems have structured their billing to separate facility fees from professional fees in ways that can result in bills not clearly covered by the law's prohibition. Patients may receive bills they believe are prohibited and pay them before realizing they should have been challenged.
Coding and billing disputes passed to patients. When providers and insurers disagree about the appropriate payment rate, some providers have sent invoices to patients during the dispute rather than pursuing the law's required arbitration process. Patients who pay those invoices may be paying amounts that the provider is not permitted to collect from them.
What to Do If You Receive a Surprise Bill
If you receive a medical bill that you believe is prohibited under the No Surprises Act, the most important thing to do is not pay it while you determine whether it is valid.
Check the bill against the law's covered situations. Was this an emergency? An out-of-network provider at an in-network facility? These are the key questions.
Contact your insurer first. Your insurer should be able to tell you whether the provider's service falls under the No Surprises Act protections and what your correct cost share is. Your insurer is supposed to apply the in-network rate; if they have not, ask them to reprocess the claim.
Request an itemized bill. You have the right to an itemized bill showing each charge. Review it against your Explanation of Benefits from your insurer.
Contact the provider's billing department. Tell them you believe the charges are subject to No Surprises Act protections and ask for documentation of any consent form you signed and the reason they believe the bill is valid.
File a complaint. If you believe your No Surprises Act rights were violated, you can file a complaint with the federal No Surprises Help Desk at 1-800-985-3059 or at cms.gov/nosurprises.² State insurance commissioners also accept complaints about potential violations.
Use your state's protections if they are stronger. Some states enacted surprise billing protections before the federal law took effect. If your state's law is more protective, it may apply in situations the federal law doesn't cover.
The Arbitration System and What It Means for Patients
The No Surprises Act created an independent dispute resolution (IDR) process for when providers and insurers disagree about what the insurer should pay.² This process was intended to keep payment disputes between providers and insurers, not between providers and patients.
The IDR process has been heavily used and heavily litigated. Provider groups challenged the regulations governing how arbitrators should make decisions, arguing that the initial rules were too favorable to insurers.³ Multiple court decisions resulted in regulatory revisions to the IDR process. The effect for patients has been indirect: when the IDR system is uncertain or contested, some providers have sent bills to patients rather than using the IDR pathway.
This is not a situation patients caused, but it is one patients sometimes find themselves in the middle of. If you receive a bill from a provider who says your insurer has not paid and you believe you are protected by the No Surprises Act, that bill should not come to you. The provider's dispute is with the insurer, and the law requires that dispute to go through IDR.
What This Means for You
The No Surprises Act was a genuine step forward for patients. It eliminated the most egregious version of the surprise bill problem, where people left an in-network emergency room only to receive a separate bill from an out-of-network physician they never chose.
But the law has limits, and it is being implemented imperfectly. Ground ambulances are still a gap. Consent forms are being used in ways that regulators are still addressing. Billing disputes are occasionally being redirected to patients inappropriately.
If you receive a bill that seems wrong given where and how you received care, it is worth spending 20 minutes verifying whether you are protected before paying. The federal complaint line exists for this situation.
Ellen can help you understand what your insurer is required to cover, how to read your Explanation of Benefits, and what steps to take when a bill doesn't match what the law allows.
Frequently Asked Questions
Does the No Surprises Act apply to all insurance?
The law applies to most group health plans and individual insurance plans. It generally does not apply to short-term plans, health care sharing ministries, or some self-pay arrangements.
What is the No Surprises Help Desk?
The federal government operates a help line at 1-800-985-3059 for patients who believe they have received a bill in violation of the No Surprises Act. You can also file a complaint online at cms.gov/nosurprises.
What if I already paid a bill that should have been prohibited?
Contact the provider's billing department and explain that the charge may have been prohibited under the No Surprises Act. You can also file a complaint with CMS or your state insurance commissioner, which may prompt a review and refund.
Are ground ambulance bills ever covered by the law?
No. Ground ambulance services are explicitly excluded from federal No Surprises Act protections. Some states have their own ground ambulance billing protections; check with your state insurance commissioner.
Sources
Ellen can help you understand your rights under the No Surprises Act and what your insurer is required to cover. Start at EllenRx.com.