Surprise Billing Protections

The No Surprises Act — enacted as part of the Consolidated Appropriations Act of 2021 and codified at 42 U.S.C. §§ 300gg-111, 300gg-131, 300gg-132 — is the landmark federal law that ended the practice of surprise medical billing: the experience of insured patients receiving unexpected, often enormous bills from out-of-network providers they never chose — typically out-of-network physicians working in in-network hospitals, or emergency room doctors treating patients who had no ability to choose their provider. Before the No Surprises Act (effective January 2022), an estimated 1 in 5 emergency room visits and 1 in 6 in-network hospital stays generated at least one surprise out-of-network bill, with median surprise bills of $600–$2,000 and some reaching tens of thousands of dollars. The Act limits patient cost-sharing for emergency care and certain non-emergency services to in-network cost-sharing levels regardless of whether the treating provider is in-network — protecting patients from the provider's full charges. Disputes between providers and insurers over what the insurer pays are resolved through an Independent Dispute Resolution (IDR) process, with arbitrators selecting one party's "baseball-style" offer. The IDR system has been heavily litigated: provider groups challenged the initial regulations as tilting toward insurers; courts struck down portions of the rules; and updated regulations have gone through multiple rounds of revision. The Act also requires good faith cost estimates for scheduled services and establishes a patient complaint system at CMS. Despite implementation challenges, the No Surprises Act is broadly credited with eliminating the most egregious surprise billing practices that had victimized patients.

Current Law (2026)

The No Surprises Act (effective 2022) protects insured patients from surprise out-of-network medical bills in emergency and certain non-emergency situations. It works alongside the ACA marketplace framework and ERISA employer plan protections.

Legal Authority

• 42 U.S.C. § 300gg-111 — No Surprises Act — requirements relating to surprise medical billing (emergency services, non-emergency at in-network facilities)
• 42 U.S.C. § 300gg-131 — Good faith estimate requirements for uninsured and self-pay patients
• 42 U.S.C. § 300gg-132 — Provider requirements regarding cost-sharing for nonparticipating providers
• Public Health Service Act Section 2799A — No Surprises Act provisions (codified at 42 USC 300gg-111 et seq.)

How It Works

Once the patient's cost-sharing is removed from the dispute, providers and insurers resolve the actual payment amount through an Independent Dispute Resolution (IDR) process — a mandatory arbitration system created by 42 U.S.C. § 300gg-111. The IDR arbitrator considers the qualifying payment amount (QPA) — the insurer's median contracted rate for the service in the geographic area — as the presumptive benchmark, along with other factors like provider credentials, market share, and prior payment history. Courts have debated how much weight the QPA must receive; the final implementing regulations have been revised multiple times following litigation challenging the QPA's dominance. Providers and insurers each pay an administrative fee for IDR; the losing party pays the arbitrator's fee.

Uninsured and self-pay patients are protected separately: providers must deliver a Good Faith Estimate (GFE) of expected costs before scheduled services. If the final bill exceeds the GFE by $400 or more, the patient can initiate a patient-provider dispute resolution process — a streamlined mechanism for resolving billing discrepancies without litigation. Providers can ask patients to waive surprise billing protections and agree to out-of-network rates — but only for non-emergency, post-stabilization, or certain scheduled services, and only after providing proper notice and obtaining written consent. Emergency services and services at in-network facilities from unavoidable out-of-network providers cannot be waived; consent obtained in the emergency room or during active treatment is not valid.

The most significant coverage gap is ground ambulance services — intentionally excluded from the No Surprises Act's scope after lobbying by ambulance providers. Balance billing for ground ambulance remains common and can be substantial (bills of $1,000–$3,000 above insurance payment are routine in some markets). Several states have enacted their own ground ambulance balance billing protections, and federal legislation to fill this gap has been proposed but not enacted as of 2026. Patients with Medicare Advantage plans have separate balance billing protections under Medicare rules that apply regardless of the NSA's coverage gaps.

How It Affects You

If you go to the emergency room: You cannot be balance-billed for emergency care — even if the hospital is out-of-network, even if the ER physician's group is not in your plan's network. Your liability is capped at your in-network cost-sharing (deductible, copay, or coinsurance based on your plan). The hospital and your insurer resolve the payment dispute through IDR; that dispute doesn't touch you. One important exception: ground ambulance is not covered by the No Surprises Act. If you're transported by out-of-network ground ambulance, you may still receive a balance bill of $1,000–$15,000+.

If you're having scheduled surgery at an in-network hospital: The No Surprises Act protects you when out-of-network providers — anesthesiologists, radiologists, assistant surgeons, pathologists — are used at an in-network facility without your advance agreement. Your cost-sharing is capped at the in-network rate. Before a procedure, ask specifically which providers will be involved and whether each is in-network with your plan. Even with these protections, knowing in advance avoids the hassle of a dispute after.

If you're asked to sign a consent-to-balance-billing waiver: Providers may ask you to waive your No Surprises Act protections for certain non-emergency scheduled services. You can legally refuse — and refusal cannot result in denial of care for protected services. The law requires these waivers to be presented at least 72 hours before the scheduled procedure (or at scheduling time if the service is within 72 hours). Consumer advocates report that some providers include these waivers in routine intake paperwork at check-in. Read anything you're asked to sign before non-emergency care.

If you're uninsured or self-pay: You're entitled to a Good Faith Estimate (GFE) before any scheduled service — an itemized list of expected charges from the provider and any co-providers involved in your care. If the final bill exceeds the GFE by more than $400, you can dispute it through the federal patient-provider dispute resolution process. Request the GFE proactively when scheduling your appointment; providers are required to provide it but may not do so automatically. For large hospital bills, also ask about the facility's financial assistance/charity care program — most hospitals have one and are required to post their financial assistance policy. If unpaid medical bills end up on your credit report, see Medical Debt Protections for your rights under current reporting rules.

Implementing Regulations

• 45 CFR Part 149 — Surprise Billing and Transparency Requirements: the primary implementing regulations for the No Surprises Act, covering both plan/insurer obligations and provider obligations. Key provisions:

  • § 149.110 — Emergency services balance billing prohibition: a group health plan or insurer must cover emergency services — regardless of whether the facility or provider is in-network — and the patient's cost-sharing obligation is capped at the in-network level; the plan cannot impose out-of-network prior authorization requirements for emergency services; the plan cannot impose out-of-network cost-sharing that is greater than the in-network cost-sharing; if the patient receives initial emergency stabilization at an out-of-network facility and is then transferred or treated for further non-emergency services, the balance billing protections continue through stabilization
  • § 149.120 — Non-emergency services at in-network facilities (the "facility scenario" provision): when a patient receives non-emergency services from an out-of-network provider at an in-network facility, the patient's cost-sharing is capped at the in-network rate; this is the "stealthy out-of-network specialist" scenario — when your in-network surgeon brings in an out-of-network assistant surgeon or anesthesiologist; consent to waive this protection is valid only if: the waiver is provided at least 72 hours in advance (or at time of scheduling if within 72 hrs), contains detailed notice of the patient's rights, identifies the specific out-of-network provider and estimated cost, and the patient signs voluntarily; waivers obtained in the emergency room or during active labor are invalid
  • § 149.130 — Air ambulance services: plans and issuers must cover air ambulance services under the same cost-sharing requirements as emergency services; air ambulance providers cannot balance-bill patients above the in-network cost-sharing amount for their plan; a dispute resolution process exists for air ambulance payment disputes; ground ambulance is specifically excluded — the No Surprises Act does not protect against ground ambulance balance billing
  • § 149.140 — Qualifying Payment Amount (QPA) methodology: the QPA is the benchmark rate used in IDR proceedings; it is calculated as the median contracted rate the plan pays to in-network providers for the same or similar service in the same geographic area; the QPA determination uses clean claims data from prior year; the QPA is a plan-specific figure, not a market average; insurers must provide QPA information to providers and to IDR arbitrators when a dispute arises; the QPA is not the amount the plan must pay — it is the benchmark around which arbitrators make their determinations, but arbitrators may select the provider's offer if it is better supported by the statutory factors
  • § 149.150 — Complaints process: CMS operates a centralized complaint portal for patients, providers, and facilities; complaints trigger investigation and potential enforcement; state insurance commissioners retain enforcement authority for state-regulated plans
  • Subpart E — Provider obligations (§§ 149.410–149.440): providers are the counterparty to the plan's obligations; they cannot balance-bill patients above the in-network cost-sharing amount for protected services; providers must give patients notice of their No Surprises Act rights; emergency facility providers must continue stabilizing emergency services regardless of the patient's insurance status pending IDR; providers who violate these provisions may face civil monetary penalties
  • Subpart F — Independent Dispute Resolution (IDR) process: when a plan and provider cannot agree on payment after the required 30-day open negotiation period, either party may initiate IDR through a certified IDR entity; each party submits a payment offer; the arbitrator selects one offer (the "baseball arbitration" model); the arbitrator considers the QPA and then applies statutory factors — provider training/experience, market share, prior contracting history, and whether the patient received advance notice — to determine which offer is appropriate; neither party is required to select the QPA as their offer; the losing party pays the arbitrator's fee; each party pays a per-dispute administrative fee to CMS; the IDR system has been heavily litigated since launch and went through multiple regulatory revisions after courts struck down the original "rebuttable presumption" that the QPA was the correct rate

  Part 149's complex structure reflects the No Surprises Act's dual approach: it protects patients by capping their out-of-pocket exposure, then creates a separate dispute resolution system for providers and plans to fight over the actual payment rate. The IDR process is controversial because: (a) it generates enormous caseload (500,000+ disputes filed in the first two years); (b) outcomes have been inconsistent, with courts repeatedly striking down regulatory implementation; and (c) both providers (who claim QPA artificially suppresses payment) and plans (who claim providers are gaming the IDR system to extract above-QPA payments) are dissatisfied. Recent rulemakings: 88 FR 75744 (November 2023) — revised IDR fee structure and arbitrator selection requirements following prior rule vacatur; 89 FR 23418 (April 2024) — updated QPA calculation methodology.

• 26 CFR Part 54 — IRS excise tax requirements for group health plans (surprise billing compliance)

Pending Legislation

• S 2420 (Sen. Marshall, R-KS) — No Surprises Act Enforcement Act: would raise penalties for surprise billing to $10,000 per violation, add 3x late-payment fines after IDR decisions, and require semiannual enforcement reports to Congress. Status: Introduced.
• HR 4710 (Rep. Murphy, R-NC) — No Surprises Act Enforcement Act: House companion, $10,000 per-failure fines, triple penalties for missed IDR payments, semiannual audit reporting. Status: Introduced.
• SJ Res 148 — Would disapprove CFPB's withdrawal of Bulletin 2022-01, keeping medical-debt collection and reporting requirements tied to the No Surprises Act in place (see CFPB). Status: Introduced.

Recent Developments

• IDR backlog and process overhaul: The Independent Dispute Resolution process has been overwhelmed since launch, with over 490,000 disputes filed and significant processing backlogs. Courts struck down portions of the original IDR implementation rules (particularly the "rebuttable presumption" favoring the qualifying payment amount), and CMS has revised the process multiple times. Arbitration entities report inconsistent outcomes, and both provider groups and insurers have expressed frustration with the system's cost and unpredictability.
• Ground ambulance gap remains: Ground ambulance balance billing is the most significant remaining gap in surprise billing protections. For the broader federal framework on healthcare spending, out-of-pocket costs remain a central policy issue. The Ground Ambulance and Patient Billing (GAB) Advisory Committee published recommendations in late 2023, but no federal legislation has been enacted. Patients transported by out-of-network ground ambulance can still face bills of $1,000-$15,000+ above what insurance pays. Some states (CO, FL, MD, NY) have enacted their own ground ambulance protections.
• CFPB enforcement rollback: The CFPB's Bulletin 2022-01, which clarified that medical debt collection practices must comply with the No Surprises Act's consumer protections, was withdrawn by the Trump administration CFPB in early 2025. Congressional disapproval resolution SJRES 148 seeks to reinstate it. Without the bulletin, enforcement of the intersection between surprise billing protections and debt collection practices is weakened.
• Consent waiver concerns: Consumer advocates report that some providers are pressuring patients to sign consent-to-balance-bill waivers before non-emergency procedures, sometimes presenting them alongside routine intake paperwork. The law requires waivers to be presented at least 72 hours before scheduled services (or at time of scheduling for services within 72 hours), and patients have the right to refuse without consequences for protected services.