Key Takeaways
- Effective January 1, 2022, the No Surprises Act protects you from most surprise medical bills
- Emergency care at any hospital must be billed at in-network rates for your cost-sharing
- Out-of-network providers at in-network facilities cannot balance bill you without proper consent
- Air ambulances are covered (but ground ambulances are not—yet)
- 120 days to dispute from the date of your Explanation of Benefits (EOB)
- 54% success rate for patients/insurers in independent dispute resolution
What Is the No Surprises Act?
The No Surprises Act is a federal law that took effect on January 1, 2022. It protects patients from receiving unexpected medical bills—called "surprise bills" or "balance bills"—when they receive:
- Emergency care from any provider or facility
- Scheduled care at an in-network facility from an out-of-network provider (like an anesthesiologist, radiologist, or assistant surgeon) who you didn't choose
- Air ambulance transport (helicopter or fixed-wing aircraft)
Before this law, hospitals and out-of-network providers could send you bills for the "balance" between what your insurance paid and what the provider charged—often tens of thousands of dollars. The No Surprises Act stops this practice by limiting what you can be charged to your in-network cost-sharing amount (your deductible, copay, or coinsurance).
Who Is Protected by the No Surprises Act?
The law covers most Americans with health insurance:
Protected
- Private health insurance (employer-sponsored plans)
- Marketplace/ACA plans (Healthcare.gov, state exchanges)
- Individual health insurance plans
- Self-funded employer plans (ERISA plans)
- Uninsured/self-paying patients (different protections)
Not Covered (Have Other Protections)
- Medicare (has its own balance billing protections)
- Medicaid (already prohibits balance billing)
- TRICARE and VA (military/veteran health programs)
- Indian Health Service
- Federal Employees Health Benefits (FEHB) plans
Important: If you have Medicare or Medicaid, you're already protected from balance billing by those programs' existing rules. You don't need the No Surprises Act—but you still can't be balance billed.
What Situations Are Protected?
1. Emergency Services
Protection: All emergency care at any hospital (in-network or out-of-network) must be billed at in-network rates for your cost-sharing.
What Counts as an Emergency:
- The "prudent layperson" standard: Would a reasonable person think this condition requires immediate care?
- Examples: Chest pain, severe bleeding, broken bones, difficulty breathing, stroke symptoms, severe burns
- Protection applies even if it turns out not to be serious
What You Pay:
- Your in-network emergency room copay (often $150-$500)
- Any in-network deductible or coinsurance
- NOT the balance between insurance payment and provider charges
Old system: You pay the $5,500 balance
No Surprises Act: You pay your in-network ER copay ($250)
No Prior Authorization Required: Your insurance cannot require you to get prior authorization for emergency care or penalize you for going to an out-of-network ER.
2. Non-Emergency Care at In-Network Facilities
Protection: If you receive scheduled care at an in-network hospital or facility, out-of-network providers working there cannot balance bill you without your informed consent.
Protected Providers Include:
- Anesthesiologists - Provide anesthesia during surgery
- Assistant Surgeons - Help with your operation
- Radiologists - Read your X-rays, MRIs, CT scans
- Pathologists - Analyze tissue samples and lab tests
- Hospitalists - Manage your care during hospital stay
- Emergency Medicine Physicians - Treat you in the ER
Old system: You pay the $4,200 balance
No Surprises Act: You pay your in-network copay/coinsurance only
Exceptions (When Balance Billing IS Allowed):
- Provider gave you written notice at least 72 hours before treatment
- Notice included a good faith cost estimate
- You had the opportunity to find an in-network provider
- You signed a consent form acknowledging out-of-network charges
3. Air Ambulance Services
Protection: Out-of-network air ambulance providers (helicopters and fixed-wing aircraft) cannot balance bill you. You pay only your in-network cost-sharing.
Old system: You pay the $30,000 balance
No Surprises Act: You pay your in-network air ambulance copay/coinsurance (often $1,000-$5,000 depending on your plan)
Ground Ambulances Are NOT Protected: Unfortunately, regular ambulances are not covered by the No Surprises Act (yet). Congress is considering adding them. Check your state laws for ground ambulance protections.
What You Actually Owe: In-Network Cost-Sharing
The No Surprises Act limits what you pay to your in-network cost-sharing amount. Here's what that means:
Deductible
The amount you pay for covered services before your insurance starts paying. Protected services count toward your in-network deductible, not out-of-network.
Copay
A fixed amount you pay for a service (e.g., $250 for an ER visit). You pay the in-network copay, not an inflated out-of-network amount.
Coinsurance
The percentage you pay after meeting your deductible (e.g., 20% of covered costs). You pay the in-network coinsurance rate on the in-network allowed amount.
Real Example: Emergency Room Visit
| Cost Component | Provider Charges | Insurance Pays | Old System (You Pay) | No Surprises Act (You Pay) |
|---|---|---|---|---|
| ER Physician | $8,000 | $2,500 | $5,500 balance | $250 copay |
| Radiology (CT scan) | $4,500 | $1,200 | $3,300 balance | $0 (included in ER visit) |
| Lab Work | $1,800 | $500 | $1,300 balance | $0 (included in ER visit) |
| TOTAL | $14,300 | $4,200 | $10,100 | $250 |
Savings: $9,850 (97.5%)
How to Dispute a Surprise Bill: Step-by-Step
If you receive a surprise bill that violates the No Surprises Act, here's exactly how to fight it:
Contact Your Insurance (Immediately)
Call your insurance company's customer service and say:
"I received a surprise medical bill for [emergency care/services at an in-network facility] from an out-of-network provider. Under the No Surprises Act, I should only be charged my in-network cost-sharing. Please reprocess this claim as an in-network service."
- Reference the No Surprises Act (effective January 1, 2022)
- Explain the provider was out-of-network without your knowledge/choice
- Request in writing that they reprocess the claim
- Document the representative's name, date, and what they said
Send Written Dispute to Provider (Same Time)
Send a certified letter (return receipt requested) to the provider stating:
- You received emergency care OR scheduled care at an in-network facility
- You did not choose an out-of-network provider
- Under the No Surprises Act, you cannot be balance billed
- You are willing to pay only your in-network cost-sharing amount
- Request immediate adjustment of the bill
File Federal Complaints (If No Response in 30 Days)
Escalate to federal agencies that enforce the No Surprises Act:
- No Surprises Help Desk: Call 1-800-985-3059 or file online complaint
- Centers for Medicare & Medicaid Services (CMS): Report provider/insurer violations
- Department of Labor: If you have an employer health plan
- Your State Insurance Commissioner: Additional state enforcement
Protect Your Credit (Immediately)
While disputing, protect yourself from collection attempts:
- Send written notice you are disputing under the No Surprises Act
- Request they halt all collection activities during dispute
- If sent to collections, send debt validation letter within 30 days
- File CFPB complaint if provider threatens collections during active dispute
- Document everything (providers face penalties for improper collection)
Independent Dispute Resolution (IDR) - If Applicable
If the dispute is between your insurer and provider about the payment amount:
- Eligibility: Bill is $400+ for protected services
- Who Initiates: Usually your insurance or the provider
- Your Role: Ensure your insurance knows you're protected
- Timeline: Must be initiated within 120 days of EOB
- Cost: Free for you (provider/insurer split $350 fee)
- Outcome: Independent arbitrator decides fair payment within 30 days
You have 120 days from receiving your Explanation of Benefits (EOB) to initiate the dispute process. Don't wait—start immediately. Providers are hoping you'll miss this deadline or not know your rights.
Common Myths & Mistakes to Avoid
Myth: "I signed a form, so I have to pay."
Truth: Waivers are only valid if you received proper notice at least 72 hours before treatment AND had a real opportunity to find an in-network alternative. Emergency care waivers are completely void. If you signed under pressure or without understanding, challenge it.
Myth: "My insurance says it's not an emergency."
Truth: The prudent layperson standard applies: If a reasonable person would think immediate care was needed, it's an emergency—even if it turned out to be minor. Your insurance can't deny emergency protections based on hindsight diagnosis.
Myth: "I have to pay now and dispute later."
Truth: DO NOT pay the full balance while disputing. Only pay what you know you owe (your in-network cost-sharing). Paying can be seen as accepting the charges. Providers cannot send you to collections during an active good-faith dispute.
Myth: "The hospital was in-network, so I'm not protected."
Truth: The opposite! If the facility is in-network, you're protected from out-of-network providers working there. The law specifically covers this scenario (like out-of-network anesthesiologists at in-network surgery centers).
Myth: "I already paid, so it's too late."
Truth: You can request a refund if you paid more than your in-network cost-sharing. Contact the provider in writing, explain you were protected by the No Surprises Act, and request a refund within 30 days. If denied, file complaints and consider small claims court.
Success Rates & What to Expect
The No Surprises Act is working. Here's what the data shows:
IDR cases won by patients/insurers (bills reduced average 68%)
Emergency bills successfully disputed to in-network rates
Anesthesiology surprise bills reduced when properly disputed
Average time to resolve dispute when patient cites the law
What makes disputes successful:
- Citing the No Surprises Act specifically (by name)
- Acting quickly (within 30 days of receiving bill)
- Documenting everything in writing
- Filing federal complaints when providers/insurers stall
- Refusing to pay more than in-network cost-sharing
- Escalating to state insurance commissioners
- Seeking media attention for egregious cases
Additional Resources
Don't Pay What You Don't Owe
The No Surprises Act gives you powerful legal protections. Providers and insurers are banking on you not knowing your rights. Now you do. Use them.
Check If Your Bill Is Protected