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Surprise Medical Billing (No Surprises Act)

The federal protection, since 2022, against a bill from an out-of-network provider the patient did not choose - the emergency room, the anaesthetist at an in-network hospital, the air ambulance - and the good-faith estimate an uninsured patient can hold a provider to.

Informational only - this is not legal advice. These definitions explain general legal vocabulary in plain English. They are not advice about your situation, reading them creates no attorney-client relationship, and the law differs from state to state and changes over time. For advice you can rely on, speak to a lawyer licensed in your state.

What it means

A surprise bill is what a patient received when they went to an in-network hospital and were treated, without choosing them, by a provider who was not in the network - the emergency physician, the anaesthetist, the radiologist, the assistant surgeon - and were then billed the difference between the provider's charge and what the plan paid. Federal law now prohibits that in three situations: emergency services, including air-ambulance transport; non-emergency services by an out-of-network provider at an in-network facility; and post-stabilisation care after an emergency. In those situations the patient owes only the in-network cost-sharing they would have paid had the provider been in network, and the provider and the plan settle the rest between themselves, by negotiation or a federal arbitration process the patient is not part of.

The protection can be waived, but only for some services and only with the patient's informed written consent given in advance on a prescribed notice - and it cannot be waived at all for emergency care, for ancillary services such as anaesthesia, pathology, radiology and diagnostics, or where no in-network provider was available. A consent form signed at the admissions desk in a stack of paperwork is a common point of dispute. Ground ambulances are not covered by the federal law, although a number of states regulate them.

For a patient with no insurance or who chooses not to use it, the same law requires a provider to give a good-faith estimate of the expected charges in advance of a scheduled service, and a patient whose final bill exceeds the estimate by more than a threshold set by regulation may bring the bill to a federal patient-provider dispute resolution process. State surprise-billing laws continue to apply to state-regulated insurance where they are at least as protective, and many are broader than the federal floor.

Where this comes from

The No Surprises Act is title I of division BB of the Consolidated Appropriations Act, 2021, codified principally at 42 U.S.C. §§ 300gg-111 to 300gg-139 and in parallel provisions of ERISA (29 U.S.C. § 1185e) and the Internal Revenue Code (26 U.S.C. § 9816); the implementing rules are at 45 C.F.R. part 149. The good-faith estimate and patient-provider dispute process are at 45 C.F.R. §§ 149.610 and 149.620. State balance-billing laws continue to apply to fully insured, state-regulated plans through the Act's deference to a "specified State law" in determining the out-of-network rate.

When people hire a lawyer for this

Most surprise bills are resolved without a lawyer: the first steps are a written dispute to the provider citing the Act, a complaint to the plan, and the federal complaint line, and a bill that falls within the three protected situations is not owed. A lawyer becomes worth the cost when a provider sues or sends the bill to collections, when the plan claims the service was not an emergency, when a signed waiver is produced, or when the amount is large enough that the good-faith-estimate dispute process is worth pursuing. Keep the estimate, the explanation of benefits and every bill.

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Part of the LawyerLand plain-English legal glossary. Definitions are written from primary sources - statutes and court rules - and each entry states the authority it rests on, or says plainly when the doctrine is state law with no national rule.

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