What is the No Surprises Act? Compliance Guide for Healthcare Practices

If you're searching for "what is the No Surprises Act" or "No Surprises Act compliance" — you're likely a healthcare provider, practice manager, or billing specialist who needs to understand this federal law. The No Surprises Act (NSA) is one of the most significant healthcare billing reforms in U.S. history, and non-compliance can cost your practice up to $10,000 per violation.

This guide covers everything you need to know: what the law is, when it was introduced, its purpose, who it applies to, what your practice must do to comply, and how to avoid penalties.

What is the No Surprises Act?

The No Surprises Act (NSA) is a federal law that protects patients from unexpected "surprise" medical bills when they receive care from out-of-network providers — particularly in emergency situations or at in-network facilities where out-of-network specialists are involved.

A "surprise bill" happens when a patient receives care at an in-network hospital but is treated by an out-of-network provider (such as an anesthesiologist, radiologist, or assistant surgeon) without their knowledge. The patient's insurance pays the out-of-network rate, and the provider then bills the patient for the remaining balance — the "balance bill." These bills can range from hundreds to tens of thousands of dollars.

The No Surprises Act prohibits balance billing in these situations and limits patient cost-sharing to in-network levels.

When Was the No Surprises Act Introduced?

The No Surprises Act was enacted as part of the Consolidated Appropriations Act of 2021, which was signed into law on December 27, 2020. The law went into effect on January 1, 2022, and has been updated with additional rules and clarifications since then.

What is the Purpose of the No Surprises Act?

The purpose of the No Surprises Act is to:

1. Protect patients from surprise medical bills — No more unexpected charges for emergency care or out-of-network services at in-network facilities
2. Limit patient cost-sharing — Patients pay no more than their in-network deductible, copay, or coinsurance for protected services
3. Establish a payment dispute process — The Independent Dispute Resolution (IDR) process allows providers and insurers to settle payment disputes without involving the patient
4. Increase price transparency — Providers must give uninsured and self-pay patients a Good Faith Estimate before scheduled services
5. Improve provider directory accuracy — Health plans must maintain accurate provider directories and update them regularly

Who Does the No Surprises Act Apply To?

The No Surprises Act applies to:

• Providers — Physicians, hospitals, ambulatory surgical centers, critical access hospitals, and air ambulance providers
• Facilities — Hospitals, hospital outpatient departments, ambulatory surgical centers, and critical access hospitals
• Health plans — Group health plans, individual health insurance coverage, and Federal Employees Health Benefits (FEHB) plans

What Services Are Protected?

The No Surprises Act protections apply to:

• Emergency services — Including post-stabilization care from out-of-network providers or facilities
• Non-emergency services at in-network facilities — When out-of-network providers (like anesthesiologists, radiologists, pathologists, assistant surgeons, hospitalists, or intensivists) provide services at an in-network hospital, ambulatory surgical center, or critical access hospital
• Air ambulance services — From out-of-network air ambulance providers

What Services Are NOT Protected?

The No Surprises Act does not protect patients from surprise bills when:

• Care is provided at an out-of-network facility for non-emergency services
• The patient signed a valid notice and consent form waiving their protections
• The service wouldn't be covered by insurance even if in-network (e.g., experimental treatment)
• The bill is for ground ambulance services (not yet covered by the NSA)

No Surprises Act Compliance Requirements

Compliance with the No Surprises Act involves several key requirements for healthcare providers and facilities:

1. No Balance Billing for Protected Services

Providers and facilities are prohibited from balance billing patients for:

• Out-of-network emergency services
• Non-emergency services provided by out-of-network providers at in-network facilities (unless notice and consent is obtained)
• Out-of-network air ambulance services

Instead, the provider must accept the payment from the insurer (typically the Qualifying Payment Amount, or QPA) plus the patient's in-network cost-sharing.

2. Disclosure of Balance Billing Protections

Providers and facilities must publicly post notices informing patients of their protections against balance billing. This includes:

• A standard notice displayed in a prominent public location in the facility
• A notice on the provider's or facility's website
• A notice included with billing statements sent to patients

The notice must include:

• A clear statement that the patient is protected from balance billing
• A description of the protections
• Information on how to file a complaint if balance billing occurs

3. Good Faith Estimates for Uninsured and Self-Pay Patients

Providers and facilities must provide a Good Faith Estimate (GFE) of expected charges to uninsured or self-pay patients:

• If the service is scheduled at least 3 business days in advance, the GFE must be provided within 1 business day of scheduling
• If the service is scheduled at least 10 business days in advance, the GFE must be provided within 3 business days of scheduling
• If a patient requests a GFE, it must be provided within 3 business days of the request

The GFE must include:

• A description of the primary service
• Diagnosis codes, service codes, and expected charges
• A list of items and services expected to be provided in conjunction with the primary service
• A list of provider(s) and facility(ies) expected to provide the services
• A disclaimer that the GFE is not a contract and actual charges may differ

4. Notice and Consent Exception

In certain circumstances, a provider can ask a patient to waive their balance billing protections by signing a notice and consent form. This exception:

• Cannot be used for emergency services before stabilization
• Cannot be used for non-emergency ancillary services (like anesthesia, pathology, radiology, or neonatology)
• Cannot be used for services furnished due to unforeseen urgent medical needs
• Can be used for post-stabilization services if the patient is stable enough to travel to an in-network facility
• Can be used for certain non-emergency services if the patient is given notice at least 72 hours in advance

The notice and consent form must include:

• A clear statement that the patient is waiving their No Surprises Act protections
• A good faith estimate of the charges
• A list of specific services that will be balance billed
• A statement that the patient is not required to consent and can use an in-network provider instead

5. Independent Dispute Resolution (IDR) Process

When a provider and insurer disagree on payment for a service covered by the No Surprises Act, they must use the federal Independent Dispute Resolution (IDR) process:

1. Open negotiation period — The provider and insurer have 30 business days to negotiate a payment amount
2. IDR submission — If no agreement is reached, either party can submit the dispute to a certified IDR entity
3. IDR determination — The certified IDR entity considers the QPA, provider's training, complexity of the case, and other factors to determine the payment amount
4. Binding decision — The IDR entity's decision is binding on both parties

The IDR process does not involve the patient — the patient is only responsible for their in-network cost-sharing.

No Surprises Act Penalties

Non-compliance with the No Surprises Act can result in significant penalties:

Penalties are assessed by the U.S. Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury. Repeat violations can result in escalating penalties and potential exclusion from federal health programs.

How to Stay Compliant: A Checklist for Your Practice

To stay compliant with the No Surprises Act, your practice should:

• Post the required disclosure notice in your waiting area and on your website
• Train your billing staff on balance billing prohibitions and the notice and consent process
• Implement a Good Faith Estimate workflow for uninsured and self-pay patients
• Verify network status of all providers at your facility before billing patients
• Use proper notice and consent forms if you plan to use the exception
• Document all communications with patients about their billing protections
• Review your billing software to ensure it flags potential balance billing violations
• Monitor IDR timelines if you enter payment disputes with insurers
• Update your patient intake forms to include NSA-related disclosures
• Audit your billing practices regularly for compliance

How Neuraline Helps with No Surprises Act Compliance

Neuraline's EHR and practice management platform includes features that help your practice stay compliant with the No Surprises Act:

• Automated Good Faith Estimates — Generate and deliver GFEs to uninsured and self-pay patients within required timeframes
• Balance billing alerts — The system flags any attempt to balance bill a patient for protected services
• Notice and consent management — Digital forms with required disclosures and patient signatures
• Provider directory integration — Real-time network status verification for all providers at your facility
• Patient disclosure tracking — Automated tracking of NSA disclosures sent to patients
• IDR workflow support — Track open negotiation periods and IDR submissions
• Compliance reporting — Audit-ready reports showing your practice's compliance with all NSA requirements

Frequently Asked Questions

Does the No Surprises Act apply to all medical bills?

No. The No Surprises Act only applies to surprise bills from out-of-network providers for emergency services, certain non-emergency services at in-network facilities, and air ambulance services. It does not apply to ground ambulance services, out-of-network facilities for non-emergency care, or services not covered by insurance.

Can a patient waive their No Surprises Act protections?

Yes, but only in specific circumstances. A patient can sign a notice and consent form to waive their protections for certain non-emergency services or post-stabilization care. The form must include a good faith estimate of charges and a clear statement that the patient is waiving their protections. Patients cannot be forced to sign, and no fees can be charged for refusing to consent.

What is the Qualifying Payment Amount (QPA)?

The QPA is the median in-network rate that insurers use as a baseline for payment determinations under the No Surprises Act. It is calculated based on the insurer's contracted rates for the same or similar service in the same geographic area. The QPA is used as a reference point in the IDR process but is not automatically the final payment amount.

How long does the IDR process take?

The IDR process begins with a 30-business-day open negotiation period. If the dispute is submitted to a certified IDR entity, the entity has 10 business days to make a determination. The entire process typically takes 40-50 business days from the initial payment dispute.

Does the No Surprises Act apply to dental or vision services?

The No Surprises Act generally applies to services covered by medical insurance. Dental and vision services are typically covered by separate dental and vision plans, which are not subject to the NSA. However, if dental or vision services are billed through a medical plan, the NSA protections may apply.

Key Takeaways

• The No Surprises Act took effect on January 1, 2022, protecting patients from surprise medical bills
• It prohibits balance billing for emergency services, certain non-emergency services at in-network facilities, and air ambulance services
• Providers must give Good Faith Estimates to uninsured and self-pay patients
• Penalties for non-compliance can reach $10,000 per violation
• The IDR process resolves payment disputes between providers and insurers without involving patients
• Compliance requires staff training, proper disclosures, and billing system updates

Staying compliant with the No Surprises Act is not optional — it's federal law. By understanding the requirements and implementing the right processes and technology, your practice can protect both your patients and your bottom line.

For more information, visit the CMS No Surprises Act page or contact the No Surprises Help Desk at 1-800-985-3059.