The No Surprises Act: What It Is and How It Protects You
Effective January 2022, federal law now protects patients from surprise medical bills in most circumstances. Here's exactly what it covers, what it doesn't, and how to invoke it in a dispute.
What the No Surprises Act does
The No Surprises Act (NSA), effective January 1, 2022, protects patients from unexpected bills from out-of-network providers they never chose — anesthesiologists, radiologists, and assistant surgeons assigned to their case at in-network facilities without their knowledge or consent.
Before this law, patients routinely received bills for thousands of dollars from out-of-network providers at in-network facilities. The NSA eliminated this practice in most circumstances.
Prohibits balance billing — charging patients more than their in-network cost-sharing — for emergency services and for non-emergency services from out-of-network providers at in-network facilities, unless the patient provides informed written consent with at least 72 hours advance notice.
What the NSA covers
- ✓Emergency services at any facility — Emergency care at any ER — you can only be charged your in-network cost-sharing amount regardless of which provider treats you, even if the ER or individual providers are out-of-network.
- ✓Out-of-network providers at in-network facilities — If you go to an in-network hospital for a scheduled procedure and an out-of-network provider treats you without your informed advance consent, they cannot balance bill you.
- ✓Out-of-network air ambulance services — Air ambulance companies that are out-of-network cannot charge you more than your in-network cost-sharing amount.
What the NSA does NOT cover
- ✗Ground ambulance services — Currently excluded from NSA protections — a known gap that Congress has debated but not resolved as of 2026. Ground ambulance bills remain a significant source of surprise charges.
- ✗Services you voluntarily chose out-of-network — If you knowingly chose an out-of-network provider with proper 72-hour advance written notice and signed a consent form, NSA protections may not apply.
- ✗Grandfathered or short-term health plans — Some plans predating the ACA or certain short-term plans may not be subject to NSA rules. Check your plan documents.
The Good Faith Estimate requirement
Uninsured or self-pay patients have an additional protection: providers must give a Good Faith Estimate of expected costs before scheduled services. If your final bill exceeds that estimate by $400 or more, you have the right to dispute it through a Patient-Provider Dispute Resolution process.
Insured patients can request a cost estimate as well, though the binding dispute process currently applies primarily to uninsured patients.
The consent exception — know your rights
Out-of-network providers can balance bill you only if they give you written notice at least 72 hours before scheduled care and you voluntarily sign a consent form acknowledging the out-of-network status and estimated costs.
If a provider asks you to sign a waiver of NSA protections on the day of a procedure — not 72 hours in advance — you can refuse. For emergency care, you cannot be asked to waive protections at all. Many patients sign these forms without realizing they have the right to decline.
How to use the NSA in a dispute
Name the specific statute. This signals you know the law and that the provider faces CMS enforcement consequences — not just a generic complaint.
Go to cms.gov/nosurprises or call 1-800-985-3059. CMS investigates NSA violations and can impose civil monetary penalties on providers who violate the law.
For insurance-related NSA disputes, your state DOI has concurrent jurisdiction and often responds faster than federal agencies.
The No Surprises Act is one of the strongest consumer protections in healthcare. A dispute letter citing 42 U.S.C. § 300gg-111 — with a CMS complaint as the escalation path — gets resolved far more quickly than a generic billing complaint. Providers know this law and respond to it.
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LetterPerfect is not a law firm. This guide is for informational purposes only and does not constitute legal advice. For legal representation, consult a licensed attorney in your state.