The No Surprises Act is a federal law that protects patients from many unexpected out-of-network medical bills. Its main consumer protections took effect on January 1, 2022. When the law applies, patients generally cannot be charged higher out-of-network amounts simply because an emergency facility or certain health care providers involved in their care were outside their insurance plan’s network.
The law is particularly important when patients have little or no practical opportunity to choose an in-network provider, for example, during an emergency or when an out-of-network anesthesiologist participates in treatment at an in-network hospital.
The No Surprises Act also limits balance billing, establishes rules for patient cost sharing, and creates a federal process for resolving certain payment disputes between health plans and providers.
What Does the No Surprises Act Do?
The No Surprises Act addresses situations in which patients receive covered medical care but unexpectedly discover that a provider, facility, or air ambulance service was outside their health plan’s network.
Two terms are important:
- Surprise billing occurs when a patient unexpectedly receives an out-of-network medical bill, often despite having sought care at an in-network facility.
- Balance billing occurs when an out-of-network provider bills a patient for the difference between the provider’s charge and the amount the insurance plan pays or recognizes.
When the No Surprises Act applies, it generally:
- Protects patients from many surprise bills for emergency services;
- Limits cost sharing for protected services to amounts generally based on in-network treatment;
- Restricts balance billing by covered out-of-network providers;
- Protects patients receiving certain non-emergency services at in-network facilities; and
- Protects patients from covered out-of-network air ambulance balance bills.
- The law does not, however, make every out-of-network medical bill illegal.
Who Does the No Surprises Act Protect?
The federal surprise-billing protections generally apply to people covered by most group health plans and individual health insurance coverage, including many employer-sponsored and Marketplace plans.
The law primarily addresses three situations:
| Medical Situation | General No Surprises Act Protection |
|---|---|
| Emergency services | Patients are generally protected from out-of-network balance bills and excessive out-of-network cost sharing. |
| Non-emergency care at an in-network facility | Certain services from out-of-network providers are protected. |
| Air ambulance services | Covered out-of-network air ambulance services generally cannot result in balance billing. |
Programs such as Medicare and Medicaid already operate under separate federal billing protections, so the No Surprises Act does not apply to them in the same way.
The Act also establishes separate protections for certain uninsured and self-pay patients, including rights related to good faith estimates of expected medical charges.
How Does the No Surprises Act Work for Emergency Services?
Emergency medical treatment is one of the law’s most important areas of protection.
Suppose a patient is rushed to the nearest emergency room and later learns that the facility or treating provider was outside the insurance network. Before the No Surprises Act, situations like this could result in substantial unexpected bills.
For covered emergency services subject to the Act, health plans generally must calculate the patient’s cost-sharing obligation without imposing higher out-of-network cost sharing simply because the emergency provider or facility was nonparticipating.
The provider or facility generally cannot bill the patient for an additional balance beyond the permitted patient cost-sharing amount.
Federal rules also generally prohibit requiring prior authorization for covered emergency services solely because care was obtained outside the plan’s network.
What Is Balance Billing in Health Insurance?
Balance billing in health insurance means an out-of-network provider bills a patient for an amount remaining after the health plan has paid its portion of the medical charge.
For example, assume a provider charges $2,000 for a service, but the patient’s health plan pays or recognizes only part of that amount. Without an applicable legal restriction, the provider may attempt to collect some or all of the remaining amount from the patient.
The No Surprises Act prohibits this practice in specified protected situations.
That distinction is important because balance billing itself is not universally prohibited. Whether it is allowed depends on the type of service, setting, insurance coverage, federal law, applicable state law, and whether any valid notice-and-consent exception applies.
What Happens if an Out-of-Network Doctor Treats You at an In-Network Hospital?
Patients can select an in-network hospital yet still unknowingly receive treatment from an out-of-network professional.
This commonly becomes an issue with services involving specialists such as:
- Anesthesiologists;
- Radiologists;
- Pathologists;
- Neonatologists;
- Hospitalists; or
- Assistant surgeons.
For covered services at participating facilities, federal law can restrict an out-of-network provider from charging the patient more than the applicable protected cost-sharing amount.
In some non-emergency situations, a provider may be able to ask a patient to waive certain protections through the federal notice-and-consent process.
However, notice and consent cannot be used in every situation. Federal rules prohibit waivers for several categories of ancillary services and generally do not allow patients to waive protections for emergency services before stabilization.
Does the No Surprises Act Apply to Physician Offices?
Not every visit to an out-of-network physician is covered.
The federal protections for non-emergency out-of-network services generally focus on services received in connection with a visit to specified in-network health care facilities, rather than ordinary care that a patient knowingly receives at an independent out-of-network physician’s office.
Therefore, a patient who intentionally schedules an appointment with an out-of-network doctor should not assume that the No Surprises Act automatically limits the bill.
Other federal requirements, insurance-contract terms, or state laws may still be relevant depending on the circumstances.
What Is the Qualifying Payment Amount Under the No Surprises Act?
The Qualifying Payment Amount (QPA) is an important concept within the No Surprises Act framework.
Broadly, the QPA is based on contracted rates for the same or similar medical service in a geographic area, calculated according to federal statutory and regulatory requirements. It can play a role in determining patient cost sharing for certain protected out-of-network services and is also relevant to disputes over how much a health plan should pay an out-of-network provider.
The precise rules governing QPA calculations are legally significant because relatively small changes in the methodology can affect payment calculations across large numbers of medical claims.
Federal regulations implementing these provisions have consequently generated litigation over how the statutory requirements should be interpreted.
How Are Out-of-Network Payment Disputes Resolved?
One of the most important features of the No Surprises Act is that it attempts to separate the patient’s financial protection from the dispute between the insurer and medical provider.
For certain qualifying out-of-network claims, providers and health plans may use the Federal Independent Dispute Resolution process, commonly called Federal IDR.
- The process generally involves:
- An initial payment or denial;
- A period of open negotiation between the parties;
- Initiation of Federal IDR if the dispute remains unresolved and is eligible; and
- A payment determination by a certified IDR entity under applicable federal requirements.
Federal rules governing IDR procedures were further updated in 2026, including rules concerning dispute eligibility, batching, notices, registration, fees, and other administrative procedures.
These disputes can also raise broader questions about federal statutory interpretation and administrative regulations. When disputes over federal law reach a U.S. court of appeals, the case becomes part of the broader federal appeals process.
What Does the No Surprises Act Not Cover?
The No Surprises Act provides significant protection, but its reach has limits.
It does not automatically protect patients from every expensive, unexpected, or out-of-network medical bill. Depending on the circumstances, federal protections may not apply to:
- Ordinary services knowingly obtained from an out-of-network physician;
- Care voluntarily obtained at an out-of-network facility;
- Services for which a legally valid notice-and-consent exception applies;
- Certain types of insurance or coverage that fall outside the Act; and
- Ground ambulance services, which are not covered by the federal surprise-billing protections in the same way as air ambulance services.
State surprise-billing laws may provide additional rights beyond federal protections, so coverage can also depend on the patient’s state and type of health plan.
What Should You Do if You Receive a Surprise Medical Bill?
Receiving an unexpected medical bill does not automatically mean the provider violated the No Surprises Act.
Patients should first compare the medical bill with their insurance plan’s Explanation of Benefits (EOB) and determine:
- Whether the provider was treated as in network or out of network;
Whether the service involved emergency care; - Whether the facility itself was in network;
- Whether the bill includes an amount beyond the patient’s stated cost-sharing responsibility; and
- Whether any notice-and-consent form was signed.
If a bill appears inconsistent with federal surprise-billing protections, consumers can contact their health plan, the provider, or the federal No Surprises Help Desk.
Uninsured and self-pay patients have an additional protection involving good faith estimates. If an eligible patient receives a bill that is at least $400 higher than the good faith estimate provided for that provider or facility, the patient may qualify for the federal patient-provider dispute resolution process.
Conclusion
The No Surprises Act protects patients from many of the most common forms of unexpected out-of-network medical billing. Its protections are strongest for emergency services, certain out-of-network services received at in-network facilities, and covered air ambulance services.
However, the law does not eliminate every balance bill or resolve every medical billing dispute. Whether a particular bill is protected can depend on the medical setting, type of coverage, provider network status, consent requirements, federal regulations, and applicable state law.
The Act has also created significant questions involving federal regulations, administrative law, and appellate review. Brownstone Law represents clients in federal appellate matters. If a federal court decision or other appeal affects your legal rights, contact Brownstone Law to discuss the appellate issues and available options.
Frequently Asked Questions
Q1. Who does the No Surprises Act apply to?
Ans. The No Surprises Act generally protects people enrolled in most group and individual health insurance coverage from certain unexpected out-of-network bills, including many employer-sponsored and Marketplace plans. Separate provisions also give certain uninsured and self-pay patients rights involving good faith estimates and billing disputes.
Q2. Does the No Surprises Act apply to physician offices?
Ans. Not necessarily. The federal protections for non-emergency services generally apply to certain out-of-network care connected with a visit to a participating health care facility. An ordinary appointment knowingly made with an independent out-of-network physician does not automatically receive the same protection.
Q3. Is balance billing legal?
Ans. Balance billing is legal in some circumstances but prohibited in others. The No Surprises Act generally prohibits balance billing for covered emergency services and certain out-of-network services received at in-network facilities. Other out-of-network services may still be balance billed when federal or state protections do not apply or when a permitted notice-and-consent exception is valid.
