healthcare-and-medical

No Surprises Act — How to Fight Illegal Surprise Medical Bills Under Federal Law

Difficulty Intermediate Risk Low Applies To All (federal law; some states have additional protections) Potential Savings $500 – $100,000+ depending on the bill Last Verified 2026-03-01

No Surprises Act — How to Fight Illegal Surprise Medical Bills Under Federal Law

What Is It?

A “surprise medical bill” occurs when you receive care at an in-network hospital or facility but are treated by an out-of-network provider — a physician, anesthesiologist, radiologist, or other specialist you did not choose and often did not even know was out of network. Until 2022, these providers could bill you for the full difference between their charge and what your insurer paid: sometimes tens of thousands of dollars.

The No Surprises Act (Division BB of the Consolidated Appropriations Act, 2021, Pub. L. 116-260), which took effect January 1, 2022, ended most surprise billing. It is enforced primarily through regulations at 45 CFR Part 149. The law limits what you can be charged in covered situations to your in-network cost-sharing amount (your normal deductible, copay, and coinsurance) — and bans the provider from billing you for any amount above that. Violating providers face civil monetary penalties of up to $10,000 per violation.

This applies whether you have employer-sponsored insurance, individual marketplace coverage, or are uninsured. Medicare and Medicaid have their own separate balance-billing protections.

What the Law Covers

The No Surprises Act bans balance billing (charging you more than in-network cost-sharing) in these specific situations:

  • Emergency services at any facility — regardless of whether the facility or the treating providers are in your network. If you are taken by ambulance to an out-of-network ER, you pay only what you would have paid at an in-network ER.
  • Non-emergency services at an in-network facility from out-of-network providers — the most common scenario. You go to an in-network hospital for a scheduled surgery; an out-of-network anesthesiologist or assistant surgeon is involved without your knowledge.
  • Air ambulance services from out-of-network providers — a major source of six-figure surprise bills, now capped at in-network cost-sharing.
  • Out-of-network services during an inpatient or outpatient stay that began with emergency services — the full episode of care is protected, not just the initial emergency.

What the law does NOT cover:

  • Ground ambulance services (a significant gap in the law — ground ambulance is excluded)
  • Services where you voluntarily chose an out-of-network provider and signed a valid consent form (see below)
  • Dental and vision services under separate benefit plans
  • Short-term health plans and some other limited coverage types

How It Works — Step by Step

Step 1 — Receive a surprise bill and identify whether it is covered. Look at your Explanation of Benefits (EOB) from your insurer. If the provider is listed as out-of-network but the facility where you received care was in-network, or if you received emergency care, the No Surprises Act almost certainly applies.

Step 2 — Contact your insurer immediately. Call the member services number on your insurance card. Tell them:

  • You received services at an in-network facility from an out-of-network provider (or received emergency services)
  • You believe the No Surprises Act applies and the provider’s billing should be limited to your in-network cost-sharing
  • Request confirmation in writing that the claim is being reprocessed correctly

The insurer is required under 45 CFR § 149.130 to apply your in-network cost-sharing and settle the payment dispute with the provider through the federal Independent Dispute Resolution (IDR) process — keeping you entirely out of the payment fight between the insurer and provider.

Step 3 — Dispute the bill directly with the provider. Send a written letter (certified mail) to the provider’s billing department stating:

  • The date and location of service, and the provider’s name
  • That the services were rendered at an in-network facility (or were emergency services)
  • That under the No Surprises Act (Pub. L. 116-260, effective January 1, 2022), and 45 CFR Part 149, balance billing is prohibited
  • That your cost-sharing obligation is limited to your in-network cost-sharing amount, as processed by your insurer
  • That you will not pay any amount above your confirmed in-network cost-sharing and will file a complaint with CMS if the billing continues

Step 4 — Do not pay the surprise bill while disputing. The law prohibits the provider from sending the disputed amount to collections while the dispute is pending under the No Surprises Act framework. Ask your insurer for written confirmation that the provider must not collect from you above the in-network cost-sharing amount.

Step 5 — File a complaint with CMS if the provider continues billing illegally. The Centers for Medicare and Medicaid Services (CMS) enforces the No Surprises Act. You can file a complaint at the CMS No Surprises Help Desk:

State insurance departments may also take complaints if your state has additional balance-billing laws. Some states (California, New York, Texas, Colorado) have protections that go beyond the federal floor.

The Good Faith Estimate Right (For the Uninsured and Self-Pay)

If you are uninsured or self-pay (no insurance or choosing not to use insurance), the No Surprises Act gives you a separate but related right: a Good Faith Estimate (GFE) of expected costs before you receive scheduled services.

  • Providers must give you a written GFE before your appointment if the service is scheduled at least 3 business days in advance.
  • The GFE must include the expected charges for the primary service and any reasonably anticipated co-providers (lab, anesthesia, etc.).
  • If your actual bill exceeds the GFE by $400 or more, you have 120 days from receiving the bill to file a dispute through the Patient-Provider Dispute Resolution (PPDR) process administered by HHS.

To use the PPDR process:

  1. Save a copy of your GFE when you receive it.
  2. When you receive the bill, compare it to the GFE.
  3. If the bill exceeds the GFE by $400+, submit your dispute to the HHS-selected dispute resolution entity at www.cms.gov/nosurprises within 120 days.
  4. Pay the $25 administrative fee (refunded to you if you win).
  5. The dispute resolution entity reviews both amounts and selects one as the final payment — either the GFE amount or the billed amount. The provider cannot pursue collections while the process is pending.

The Provider-Insurer Independent Dispute Resolution (IDR) Process

When you have insurance and a provider disputes how much the insurer paid them, the fight is between the provider and the insurer — not you. Under 45 CFR § 149.510, this goes through a federal IDR process:

  1. After the insurer pays the provider based on in-network rates, the provider can initiate a 30-business-day open negotiation period.
  2. If negotiation fails, either party initiates the IDR process through the federal IDR portal.
  3. A federally certified IDR entity is selected and must issue a determination within 30 days.
  4. The IDR entity picks one of the two submitted offers (“baseball arbitration” style).
  5. The losing party pays the $200–$500 IDR administrative fee; you pay nothing.

As a patient, your cost-sharing is locked in at the in-network level regardless of how the IDR resolves between the provider and insurer.

What Most People Don’t Know

  • The “consent exception” is narrow. Out-of-network providers can legally bill you at out-of-network rates if you signed a voluntary consent form acknowledging you were choosing an out-of-network provider when an in-network option was available. But this consent must be obtained at least 72 hours before a scheduled service (or 3 hours before same-day), must list the estimated costs, and cannot be requested in a true emergency. Consents signed in an ER or under any duress are not valid. Many providers try to use improperly obtained consents — you can challenge these.

  • Your right applies even if you did not know you were receiving out-of-network care. The law does not require you to have objected in advance or to have known the provider was out of network. The protection is automatic.

  • Air ambulance bills averaging $36,000–$97,000 are now covered. This was one of the most devastating sources of surprise bills. The No Surprises Act capped your cost-sharing at the in-network equivalent.

  • The law covers freestanding emergency rooms and urgent care classified as ERs. Some freestanding ERs that are not affiliated with in-network hospitals were a major source of surprise bills. The law generally covers emergency services at any facility that provides them.

  • Some employer plans are “self-funded” and have federal exemptions. Fully insured plans (where the employer buys a policy from an insurer) are covered by the No Surprises Act. Self-funded plans (where the employer pays claims directly) are regulated under ERISA and are also generally subject to the No Surprises Act under separate DOL enforcement. If your employer’s plan is self-funded, the same protections should apply, but enforcement goes through the Department of Labor rather than your state insurance department.

  • State laws may give you more protection. States like California, New York, Colorado, and Washington have additional balance-billing protections that cover situations the federal law does not (e.g., some ground ambulance situations in certain states).

Who Benefits Most?

Anyone who:

  • Goes to an in-network emergency room and receives bills from out-of-network ER physicians, radiologists, or other specialists
  • Has surgery at an in-network hospital and receives surprise bills from an out-of-network anesthesiologist or assistant surgeon
  • Was airlifted by an out-of-network air ambulance
  • Is uninsured and received a bill significantly higher than the Good Faith Estimate
  • No Surprises Act, Division BB, Consolidated Appropriations Act, 2021 (Pub. L. 116-260) — The federal statute enacted December 27, 2020, effective January 1, 2022.
  • 45 CFR Part 149 — HHS implementing regulations covering surprise billing and transparency requirements for health insurance issuers.
  • 29 CFR Part 2590 (DOL) and 26 CFR Part 54 (IRS/Treasury) — Parallel implementing regulations covering employer-sponsored group health plans under ERISA.
  • 45 CFR § 149.130 — Prohibition on balance billing for emergency services and non-emergency services at in-network facilities.
  • 45 CFR § 149.610 — Good Faith Estimate requirements for uninsured and self-pay patients.
  • 45 CFR § 149.620 — Patient-Provider Dispute Resolution (PPDR) process for uninsured/self-pay patients.
  • 45 CFR § 149.510 — Federal Independent Dispute Resolution (IDR) process between providers and health plans.

Frequently Asked Questions

I signed a form at the hospital — did I waive my No Surprises Act rights?

Almost certainly not for emergency care. The law’s “consent exception” only applies in narrow, non-emergency situations where you voluntarily chose an out-of-network provider when an in-network alternative was available, the consent was given at least 72 hours before a scheduled procedure (or 3 hours for same-day scheduling), and the form listed the estimated costs. Consents signed in an emergency room or under any form of duress are not valid. Many providers misuse consent forms — you can challenge them.

My insurer already paid part of the bill — how do I know if I still owe the balance?

Review your Explanation of Benefits (EOB). If the provider is listed as out-of-network but the facility was in-network, or if you received emergency services, your cost-sharing should have been processed at the in-network rate. If your EOB shows out-of-network cost-sharing or an “additional patient responsibility” beyond your normal in-network deductible and copay, call your insurer and ask them to reprocess the claim under the No Surprises Act (45 CFR § 149.130).

The surprise bill is from an anesthesiologist I never chose — does the No Surprises Act cover that?

Yes. One of the most common surprise billing scenarios is receiving a bill from an out-of-network anesthesiologist, radiologist, or assistant surgeon at an in-network facility for a scheduled procedure. The No Surprises Act specifically covers out-of-network provider bills for non-emergency services at in-network facilities, even when you had no choice in selecting that provider.

I’m self-pay (no insurance) and my bill is $800 more than the Good Faith Estimate I received. What do I do?

File a dispute through the Patient-Provider Dispute Resolution (PPDR) process at cms.gov/nosurprises within 120 days of receiving the bill. Pay the $25 administrative fee (refunded if you win). The dispute resolution entity will select either the GFE amount or the billed amount as the final payment. The threshold to dispute is $400 over the estimate — so an $800 discrepancy qualifies.

Can the provider send my disputed balance to collections while the No Surprises Act dispute is pending?

No. The provider cannot send the disputed balance to collections while the dispute is being processed. Ask your insurer for written confirmation of this protection and note it in any correspondence with the provider. If a collection action begins on a disputed amount, file a complaint immediately with CMS at 1-800-985-3059.

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