The No Surprises Act and Medical Billing: What Providers Must Know

The No Surprises Act (NSA), enacted as part of the Consolidated Appropriations Act of 2021 and effective January 1, 2022, protects patients from surprise out-of-network medical bills in three specific scenarios: emergency services regardless of network status (a patient who goes to an in-network ER but is treated by an out-of-network emergency physician cannot be balance billed), non-emergency services at in-network facilities from out-of-network providers (the most common situation involves out-of-network anesthesiologists, radiologists, pathologists, neonatologists, and assistant surgeons who the patient did not choose and often did not know were out-of-network), and air ambulance services from out-of-network providers. For these protected services, providers cannot balance bill patients beyond the in-network cost-sharing amount. The patient pays only what they would owe under their plan's in-network benefits — their copay, coinsurance, and deductible. Any remaining balance between the in-network cost-sharing amount and the provider's charge must be resolved between the provider and the payer, either through negotiation or the Independent Dispute Resolution (IDR) process. Four years into implementation, the NSA has fundamentally reshaped revenue-cycle operations for emergency departments, hospital-based specialties, and any practice that regularly sees out-of-network patients at in-network facilities.

For emergency departments and hospital-based specialists, the NSA eliminated the ability to balance bill patients for the difference between the provider's charge and the payer's out-of-network payment. Before the NSA, an out-of-network emergency physician who charged $1,200 for a visit where the payer allowed $400 could bill the patient for the $800 difference. Under the NSA, the patient owes only their in-network cost-sharing amount (perhaps $50 for an ER copay), and the provider must pursue the remaining balance through negotiation or IDR with the payer. The financial impact has been substantial: emergency medicine groups report 10 to 25% revenue reductions in their out-of-network revenue since the NSA took effect, though IDR outcomes have partially offset those losses when providers use the process effectively. For billing operations, the NSA requires system-level changes: your practice management system must identify NSA-protected claims (based on place of service, provider network status, and service type), suppress balance bills on those claims automatically, calculate the patient's in-network cost-sharing amount correctly, and route payment disputes to the IDR process when the payer's initial payment is below expected reimbursement. Failure to suppress a balance bill on an NSA-protected claim is a violation regardless of intent — the penalty is up to $10,000 per occurrence.

When a provider disagrees with a payer's payment for an NSA-protected claim, the Independent Dispute Resolution (IDR) process is the resolution mechanism. The process works as follows: after receiving the payer's initial payment or denial, the provider has 30 business days to initiate a 30-day open negotiation period with the payer. During this window, both parties attempt to reach a mutually agreeable payment amount. If negotiation fails, either party can submit the dispute to a certified IDR entity within four business days by filing through the federal IDR portal at nsa-idr.cms.gov. Both parties submit their best offer — a specific dollar amount with supporting documentation — to the IDR entity. The IDR entity reviews both submissions and selects one offer or the other. This is baseball-style arbitration: the entity picks one number, not a middle ground. This structure incentivizes both parties to submit reasonable offers because an extreme position risks being rejected entirely. The IDR entity must consider: the qualifying payment amount (QPA), which is the payer's median in-network rate for the same service in the same geographic area; the provider's training, experience, and quality outcomes; the complexity and acuity of the service; market share and prior contract history; and the provider's teaching status if applicable. After the Texas Medical Association v. HHS ruling struck down the original regulation that gave disproportionate weight to the QPA, the revised rule treats all factors equally. IDR filing fees for 2026 are $50 per dispute. The losing party pays the certified IDR entity's fee, which ranges from $200 to $700 for single determinations.

The NSA requires providers and facilities to give uninsured and self-pay patients a Good Faith Estimate (GFE) of expected charges before delivering scheduled services. The GFE must include the patient's name and date of birth, a description of each item or service expected to be provided, the expected charge for each item or service (using the provider's cash rate), the NPI and TIN of each provider or facility expected to furnish services, applicable diagnosis codes, and a list of items or services that the provider reasonably expects to be furnished in conjunction with the primary service (for example, anesthesia services associated with a scheduled surgery). Timing requirements: for services scheduled at least three business days in advance, the GFE must be provided within one business day of scheduling. For services scheduled at least 10 business days in advance, the GFE must be provided within three business days. If the actual bill exceeds the GFE by $400 or more, the patient can dispute the bill through the patient-provider dispute resolution (PPDR) process. If the dispute entity agrees with the patient, the practice may be required to reduce the bill. Failing to provide GFEs can trigger civil monetary penalties of up to $10,000 per violation. This means your GFEs must be comprehensive and reasonably accurate — underestimating to attract patients creates significant compliance and financial risk.

The NSA is a federal floor, not a ceiling. If a state has a surprise-billing law that provides equal or greater patient protection, the state law governs for state-regulated plans (fully insured commercial plans purchased by employers from insurance carriers). The federal NSA applies to self-insured employer plans (ERISA plans) because states cannot regulate those. As of 2026, 35 states plus Washington DC have their own surprise-billing laws, many of which predate the NSA. States like New York, California, Florida, and Texas have stricter requirements and different dispute-resolution processes. Some states mandate specific payment benchmarks (New York requires payment at the greater of the usual and customary rate or the payer's in-network median), while the federal NSA uses the QPA as just one of several factors. Your billing operation must determine whether each patient's plan is fully insured (state law applies) or self-insured (federal NSA applies) and apply the correct rules. Most payer portals indicate plan type during eligibility verification. For employer-sponsored plans, the plan document specifies whether the plan is fully insured or self-insured. Getting this determination wrong means applying the wrong balance-billing rules and the wrong dispute-resolution process.

Use this checklist to verify your practice's NSA compliance. Post the CMS-mandated patient rights notice in your facility — the notice is available for download at cms.gov/nosurprises and must be displayed in patient-facing areas and on your website. Generate and deliver Good Faith Estimates for every uninsured and self-pay patient within the required timeframes. Configure your practice management system to flag NSA-protected claims and suppress balance bills automatically — work with your PM vendor to implement claim-type logic based on POS, provider network status, and service category. Use the CMS-approved notice-and-consent form when an out-of-network provider at an in-network facility wants to balance bill a patient for a non-emergency, non-ancillary service (the patient must sign at least 72 hours in advance, and certain services like anesthesiology and pathology cannot be waived). Train front-desk, billing, and clinical staff on NSA requirements at least annually. Establish a workflow for initiating IDR when payer payments on NSA-protected claims fall below expected reimbursement. Maintain records of all GFEs, patient notices, consent forms, and IDR filings for at least seven years. Go Medical Billing manages NSA compliance for all clients, including automated GFE generation, balance-bill suppression, and IDR filing when appropriate.

Not every underpaid NSA-protected claim is worth pursuing through IDR, but for claims where the payer's initial payment is significantly below your contracted or usual rate, the IDR process can recover substantial revenue. To maximize IDR success: submit a reasonable offer supported by documentation — include your usual charge, the Medicare rate for the service as a reference point, regional market data from FAIR Health or similar databases, and any relevant clinical complexity factors. The 2024 and 2025 IDR outcomes show that providers win approximately 65% of single-service disputes when their offer is well-documented and reasonable (within 200 to 300% of Medicare). Providers who submit extreme offers — five to ten times Medicare — lose the majority of their disputes. Batch similar claims when possible: disputes involving the same payer, same service, and same geographic area can be batched, reducing the per-claim filing cost from $50 to $25. Document patient acuity, clinical complexity, and any unusual circumstances that justify higher reimbursement. Time your filings strategically: submit within the 30-business-day window but allow enough time to assemble complete supporting documentation. Go Medical Billing tracks IDR-eligible claims for all clients and initiates dispute filings when the expected recovery justifies the filing costs.