You go to an in-network hospital for emergency surgery. The hospital is covered by your insurance. The surgeon is covered. But three weeks later, you receive a separate bill from the anesthesiologist, who turns out to be employed by an outside group your insurance does not cover. The bill is for $4,000. You had no idea this person was out of network. You had no way to check in advance.
This situation was standard practice in American healthcare for decades. The No Surprises Act changed it.
In summary
The No Surprises Act, effective January 1, 2022, prohibits most out-of-network providers from billing patients more than their in-network cost-sharing amount for emergency services and for scheduled care at in-network facilities where the patient had no meaningful choice of provider. If you receive a surprise out-of-network bill that should be covered by the law, your liability is capped at your in-network deductible and copay. Disputes are handled through a federal process, not through the provider directly.
What the No Surprises Act actually prohibits
The No Surprises Act prohibits out-of-network providers from billing patients above their in-network cost-sharing amount in two situations: emergency services at any facility regardless of network status, and non-emergency care at in-network facilities where the patient had no meaningful choice of provider.
Emergency services
If you receive emergency services at any facility, whether it is in-network or out-of-network, providers cannot bill you more than your in-network cost-sharing amount. This applies to the emergency room visit itself, all services delivered in connection with that visit, and services provided until you are stabilized. The rule applies regardless of whether you had any ability to choose providers.
This is the strongest protection in the law. In an genuine emergency, you cannot shop for in-network providers. Congress recognized this and eliminated the balance billing exposure entirely for emergency care.
Scheduled services at in-network facilities
For non-emergency procedures at an in-network facility, the law prohibits out-of-network providers from billing you the balance if you did not have the practical ability to choose an in-network alternative. This covers situations like surgery where the anesthesiologist, surgical assistant, or radiologist is out of network and you had no advance notice and no real choice.
There is an important exception here: if you were given proper written notice that a specific provider was out of network and you signed a consent form acknowledging that and agreeing to pay the higher cost, the law may not protect you for that specific provider. The notice must be given at least 72 hours before a scheduled procedure, or on the day of scheduling if the procedure is within 72 hours.
What the No Surprises Act does not cover
The No Surprises Act does not cover ground ambulances, services at out-of-network facilities the patient chose voluntarily, or situations where valid written advance consent to out-of-network billing was properly obtained. Understanding them prevents frustration when you discover that a specific bill is not covered.
Ground ambulance services
Ground ambulances were explicitly excluded from the No Surprises Act. This was one of the most contested points during the legislative process, and it remains a major gap. If you received a ground ambulance bill from an out-of-network provider, the federal law does not help you. Some states have their own surprise billing protections for ground ambulances, so check your state's insurance commissioner website.
Services at out-of-network facilities
If you chose to go to an out-of-network hospital or surgery center, the No Surprises Act generally does not apply, except for genuine emergency situations. Choosing an out-of-network facility for a scheduled procedure means you accepted the out-of-network cost-sharing for all services provided there.
Air ambulance services (partially covered)
Air ambulances are covered by the No Surprises Act in some circumstances, but the rules are more complex than for hospital care. If you received an air ambulance bill and were transported without any ability to choose, it is worth checking whether the law applies to your specific situation.
How to check if the No Surprises Act applies to your bill
Work through these four questions in order.
First: Was this an emergency, or a scheduled procedure at an in-network facility? If neither, the federal law likely does not apply.
Second: Did the provider give you a written notice in advance explaining that they were out of network and asking you to consent to the out-of-network billing? If you never signed such a notice, the law almost certainly applies.
Third: Is the bill from a provider you had no practical ability to choose, such as an anesthesiologist, radiologist, assistant surgeon, or pathologist? These "facility-based providers" are the most common source of surprise bills, and they are squarely within the law's intended scope.
Fourth: Does your insurance plan fall under federal law? Most employer-sponsored plans and individual market plans do. Some church plans and certain self-funded state and local government plans may be exempt. If you are unsure, call your insurer and ask directly.
What to do when you receive a surprise out-of-network bill
Step 1: Contact your insurer first
Call the member services number on your insurance card and explain that you received an out-of-network bill for services you believe are covered under the No Surprises Act. Ask your insurer to confirm whether the law applies and to process the claim at the in-network rate. Insurers are required to count No Surprises Act claims toward your in-network deductible and out-of-pocket maximum. See the full step-by-step dispute guide.
Step 2: Do not pay the bill while the dispute is pending
Paying a bill, even partially, can be interpreted as accepting the charges. While you are disputing, send a letter to the provider explaining that you believe the bill is subject to the No Surprises Act and that you are working with your insurer to resolve the correct cost-sharing amount. Keep copies of everything.
Step 3: Use the federal No Surprises Help Desk
If your insurer does not resolve the issue or the provider continues to pursue the balance, contact the No Surprises Help Desk at 1-800-985-3059 or file a complaint at cms.gov/nosurprises. The Centers for Medicare and Medicaid Services investigates complaints and can take enforcement action against providers who violate the law.
Step 4: File a state-level complaint if applicable
Many states had their own surprise billing protections before the federal law, and some go further. Filing with both federal and state regulators increases the pressure on non-compliant providers. Your state's Department of Insurance website will have the complaint process. See the full guide to out-of-network billing disputes.
The provider dispute process
The No Surprises Act also established an arbitration process for disputes between insurers and providers, called the Independent Dispute Resolution (IDR) process. This is separate from your situation as a patient. The IDR process determines what the insurer pays the out-of-network provider. As the patient, your liability is already capped at the in-network amount regardless of how that insurer-provider dispute resolves. You do not participate in the IDR process and its outcome does not change your cost-sharing.
Frequently asked questions
Does the No Surprises Act apply to emergency room visits at out-of-network hospitals?
Yes. For emergency services, the law applies regardless of whether the facility itself is in-network or out-of-network. Your cost-sharing cannot exceed the in-network amount for emergency care at any facility, including one that is not in your insurer's network.
Can a hospital send me to collections while I dispute a No Surprises Act bill?
Providers are prohibited from taking certain adverse actions, including sending a bill to collections, while a complaint is under review by federal or state authorities. File your complaint promptly if you receive a collections threat on a No Surprises Act bill. Document the threat and include it in your complaint.
What if I already paid a surprise bill before learning about the No Surprises Act?
You may still be able to recover the overpayment. If the services were rendered on or after January 1, 2022, you can file a complaint and request a refund of the amount you paid above your in-network cost-sharing. The process is more complex for already-paid bills, but it is not foreclosed.
Does the No Surprises Act apply to Medicaid or Medicare patients?
The No Surprises Act primarily applies to private insurance plans. Medicaid and Medicare have their own rules governing provider payments and patient cost-sharing. However, if you have a private Medicare Advantage plan, the No Surprises Act provisions generally do apply.
How long does the federal complaint process take?
The CMS investigation timeline varies. Straightforward cases can be resolved in a few weeks. More complex situations may take several months. While the investigation is pending, the provider should not pursue collection on the disputed amount. Keep documentation of all communications and follow up with CMS if you do not receive a response within 60 days.
Disclaimer: The information on this page is provided for educational purposes only and does not constitute medical, legal, or financial advice. BillSurgery is not a licensed medical billing advocate, attorney, or healthcare provider. Results vary based on individual bill complexity and provider response. Replace this disclaimer with lawyer-reviewed language before publishing to general audiences.