The No Surprises Act: What It Means

The No Surprises Act: What It Means for Healthcare Providers

Unexpected medical bills can damage a patient’s finances—and their trust in the healthcare system. The No Surprises Act was created to protect patients from certain unexpected out-of-network charges, but compliance places important responsibilities on providers and their administrative teams.

For many practices, this is more than a billing issue. It affects scheduling, insurance verification, patient communication, cost estimates, documentation, claim follow-up, and payment disputes.

What Is the No Surprises Act?

The No Surprises Act is a federal law that took effect on January 1, 2022. It generally protects patients from unexpected out-of-network bills involving:

• Emergency services received from an out-of-network provider or facility
• Certain non-emergency services provided by out-of-network professionals during a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center
• Covered air ambulance services provided by an out-of-network company

In these situations, patients generally cannot be charged more than their applicable in-network cost-sharing amount. Providers are also generally prohibited from billing patients for the remaining balance. Learn more from CMS.

How the Act Affects Providers

1. Balance billing is restricted

When a service is protected by the No Surprises Act, an out-of-network provider generally cannot bill the patient for the difference between the provider’s charge and the amount paid by the health plan.

This makes accurate claim identification essential. Billing teams must be able to determine:

• Whether the service falls under federal or state surprise-billing protections
• Whether the patient received emergency or non-emergency care
• Whether the provider and facility were in-network
• What cost-sharing amount may legally be collected from the patient
• Whether a notice-and-consent exception is permitted

A claim handled incorrectly can result in patient complaints, refunds, rework, delayed payment, or compliance exposure.

2. Notice and consent have strict limitations

In some non-emergency situations, an out-of-network provider may ask a patient to consent to receiving out-of-network care and accept the related costs. However, providing a form does not automatically make balance billing permissible.

The notice must meet federal timing, format, language, and delivery requirements. It must also include a good-faith estimate of the amount the patient may be charged.

Certain services cannot use the notice-and-consent exception. These generally include emergency medicine, anesthesiology, pathology, radiology, neonatology, diagnostic services, and services provided by assistant surgeons, hospitalists, and intensivists. The exception is also unavailable when no in-network provider is able to perform the service at the facility. Review CMS provider guidance.

Staff should never treat notice and consent as just another registration form. The workflow must identify when consent is allowed, deliver the correct documents within the required timeframe, and preserve evidence that all requirements were met.

3. Good Faith Estimates are required for uninsured and self-pay patients

Providers and facilities must give uninsured or self-pay patients a Good Faith Estimate when care is scheduled or when an estimate is requested.

The estimate should clearly describe the expected charges for the scheduled services. This requires coordination among scheduling, clinical, coding, and billing teams. If the information used to prepare the estimate is incomplete, the final bill may be significantly different from what the patient expected.

A patient may be able to initiate the federal patient-provider dispute resolution process when a bill from a particular provider or facility is at least $400 more than the applicable Good Faith Estimate. See CMS Good Faith Estimate guidance.

Good Faith Estimates should not be viewed as paperwork completed only to satisfy a regulation. They are also an opportunity to improve price transparency, establish realistic expectations, and build patient trust before services are delivered.

4. Practices have disclosure responsibilities

Providers and healthcare facilities subject to the disclosure requirements must inform patients about their protections against surprise billing. Depending on the practice and where services are furnished, this may include:

• Posting information in a prominent location
• Making the notice easily accessible on the practice’s public website
• Giving covered patients a written notice within the required timeframe
• Providing information about applicable state protections
• Explaining where patients can report suspected violations

Practices should periodically review their website, registration materials, financial policies, and posted notices to make sure the information remains accurate and accessible.

5. Payment disputes require a disciplined process

When an out-of-network provider disagrees with a health plan’s payment for a qualifying service, the disagreement is generally between the provider and the payer—not the patient.

The federal Independent Dispute Resolution process may be available after the required 30-business-day open negotiation period. If the parties do not reach an agreement, an eligible dispute generally must be initiated within four business days after that negotiation period ends. Review the current IDR process and deadlines.

These short deadlines make clear ownership essential. Practices need a system for reviewing remittance information, identifying eligible claims, beginning negotiations, collecting supporting documentation, and escalating unresolved disputes.

Without a defined workflow, practices may lose the opportunity to challenge an inadequate payment simply because a deadline was missed.

The Operational and Financial Impact

The No Surprises Act creates additional administrative work at several points in the patient and revenue cycles:

• Verifying network participation before care
• Identifying protected services
• Communicating expected patient costs
• Preparing Good Faith Estimates
• Collecting only permitted cost-sharing amounts
• Maintaining compliant notices and consent records
• Reviewing remittance advice
• Tracking negotiation and dispute deadlines
• Responding to patient complaints
• Issuing refunds when necessary

If these responsibilities are divided among several employees without clearly defined ownership, work can easily be missed or duplicated.

The result may be delayed reimbursement, preventable write-offs, inconsistent patient communication, and greater staff frustration.

Five Steps Providers Can Take Now

Practices can reduce risk by reviewing five key areas:

1. Map the workflow. Follow a protected claim from scheduling through final payment and identify every person who touches it.
2. Clarify ownership. Assign responsibility for eligibility verification, estimates, notices, consent documentation, payment review, and dispute deadlines.
3. Review patient communications. Make sure staff can explain estimates and billing protections in plain language without offering legal interpretations.
4. Audit a sample of claims. Confirm that protected claims received the correct cost-sharing treatment and were not improperly balance billed.
5. Track recurring problems. Monitor inaccurate estimates, payer underpayments, missed deadlines, patient complaints, and avoidable refunds.

Compliance and Revenue Cycle Performance Must Work Together

The No Surprises Act is designed to protect patients, but successful compliance depends heavily on the strength of a practice’s daily operations.

A policy stored in a binder is not enough. The requirements must be built into scheduling, registration, billing, payment posting, and follow-up workflows.

When those workflows are clear, practices can provide a better patient experience, reduce rework, respond to payment disputes more effectively, and protect the revenue they have earned.

Guided Care Quality Solutions helps healthcare practices identify where administrative work and revenue are getting stuck. If you are unsure whether your current billing and patient-estimate workflows support No Surprises Act compliance, schedule a complimentary Practice Analysis to identify gaps and practical opportunities for improvement.

This article is provided for general educational purposes and is not legal advice. No Surprises Act requirements may interact with state laws and are subject to updated federal regulations and guidance.