Before 2022, one in five ER visits resulted in a surprise bill—an unexpected charge from a doctor or provider who wasn’t in your insurance network, even though you went to an in-network hospital. The average surprise bill was $1,219. The No Surprises Act changed that. Here’s what the law actually covers, where the gaps are, and exactly what to do if you get a bill that violates it.
1. What the No Surprises Act covers
The No Surprises Act (NSA) protects you in three specific scenarios:
a) Emergency services
If you go to an ER, you cannot be billed at out-of-network rates—regardless of whether the hospital or any provider who treats you is in your network. This includes the ER physician, radiologist, anesthesiologist, and any specialist called in during your emergency visit. (For more on how ER bills work, see our ER bill guide.)
What this means for your bill: Your cost-sharing (deductible, copay, coinsurance) must be calculated at in-network rates. The provider cannot bill you for the difference between what they charge and what your insurance pays (this practice was called “balance billing”).
b) Out-of-network providers at in-network facilities
If you go to an in-network hospital for a scheduled procedure and are treated by an out-of-network provider you didn’t choose (a common scenario with anesthesiologists, pathologists, and radiologists), you’re protected. The out-of-network provider must bill you at in-network rates.
c) Air ambulance services
Out-of-network air ambulance providers cannot balance bill you. Your cost-sharing is limited to in-network rates. (Note: ground ambulances are not covered.)
2. What it does NOT cover
The No Surprises Act has important gaps:
| Not Covered | Why It Matters |
|---|---|
| Ground ambulances | Average ground ambulance bill: $1,200. Out-of-network ground ambulance bills remain a major source of surprise charges. |
| Out-of-network providers you consent to | If you sign a written consent form agreeing to out-of-network care at least 72 hours before a scheduled service, the NSA protections may not apply. |
| Post-stabilization transfers | After an ER visit, if you are stable and voluntarily transfer to an out-of-network facility, the NSA may not cover the transfer facility’s charges. |
| Medicare, Medicaid, TRICARE, VA | These programs have their own billing protections. The NSA specifically applies to commercial insurance plans. |
| Non-emergency out-of-network care you choose | If you voluntarily go to an out-of-network provider for non-emergency care, standard out-of-network billing applies. |
3. How the protections work in practice
Here’s what happens behind the scenes when the NSA applies to your bill:
- You receive care. An out-of-network provider treats you in a covered scenario (ER visit, or at an in-network facility).
- The provider bills your insurance. Your insurer processes the claim and calculates your cost-sharing at in-network rates.
- You pay only in-network cost-sharing. Your deductible, copay, and coinsurance are based on your plan’s in-network rates. No balance billing.
- Provider and insurer negotiate. If the provider and insurer disagree on payment, they enter an Independent Dispute Resolution (IDR) process. This happens between them—you are not involved and owe nothing additional.
Example: How the NSA saves you money
You go to an in-network ER with chest pain. The ER doctor is in-network, but the cardiologist called in to read your EKG is out-of-network. The cardiologist bills $1,800 for an interpretation (CPT 93010).
Without the NSA: Your insurance pays the “out-of-network allowable” of $250. The cardiologist bills you for the remaining $1,550. You owe $1,550 in surprise charges plus your normal copay.
With the NSA: Your insurance processes the claim at in-network rates. Your copay/coinsurance is calculated on the in-network rate (let’s say $300). You owe your normal cost-sharing on $300—perhaps $60 in coinsurance. The cardiologist and your insurer sort out the rest.
Savings: $1,490.
4. Good faith estimates for uninsured patients
If you are uninsured or choose to self-pay, the No Surprises Act gives you a separate set of protections. (For additional strategies to reduce your bill as an uninsured patient, see our negotiation guide.)
- Right to a good faith estimate: Before any scheduled service, the provider must give you a written estimate of expected charges. You can also request one at any time.
- $400 dispute threshold: If the final bill exceeds the good faith estimate by $400 or more, you can dispute it through the patient-provider dispute resolution process.
- 120-day filing window: You have 120 days from the date of the bill to initiate a dispute.
- Independent review: A third-party reviewer examines the estimate and the final bill. If they side with you, the provider must accept a payment amount determined by the reviewer.
5. How to spot a No Surprises Act violation
Here’s what a surprise bill looks like in practice. This patient went to an in-network ER, but the radiologist and anesthesiologist were out-of-network:
Under the No Surprises Act, the patient should owe only their in-network cost-sharing on the two surprise bills—not $2,900. If these were processed at in-network rates (approximately $180 + $240 in cost-sharing), the savings would be $2,480.
Check your bill for these red flags:
| Red Flag | What It Means | Example |
|---|---|---|
| “Out-of-network” charges on an ER bill | ER visits are always covered by the NSA, regardless of network status. | An ER radiologist’s bill says “out-of-network, patient responsibility: $2,100” |
| Balance billing from a provider you didn’t choose | If you went to an in-network hospital and received an out-of-network provider bill, this may violate the NSA. | An anesthesiologist sends a separate $3,400 bill for a surgery at an in-network hospital. |
| Cost-sharing above in-network rates | Your copay/coinsurance should be calculated at in-network rates for NSA-covered services. | Your insurer applies a $5,000 out-of-network deductible instead of your $1,500 in-network deductible for an ER visit. |
| A bill that exceeds a good faith estimate by $400+ | If you’re uninsured and received a written estimate, the $400 threshold triggers dispute rights. | Estimate said $3,200 for a knee MRI; final bill is $4,800. |
If you suspect a surprise bill, look up the CPT codes to see what the in-network rate should be. The gap between what you were billed and the Medicare benchmark gives you a sense of how much may be in dispute:
You can also upload your bill to BillKarma and our scanner automatically checks for potential No Surprises Act violations alongside other billing errors.
6. What to do if you get a surprise bill
- Confirm the NSA applies. Was it an emergency visit? Was it an out-of-network provider at an in-network facility you didn’t consent to? If yes, you’re protected.
- Contact your insurance company. Call the member services number on your insurance card. Tell them you believe you have a No Surprises Act-protected claim and ask them to reprocess it at in-network rates.
- Contact the provider’s billing department. Tell them the bill violates the No Surprises Act. Cite the specific situation (emergency care, or out-of-network provider at an in-network facility). Request they resubmit to your insurer or adjust the bill.
- Do not pay the surprise amount. Pay only your in-network cost-sharing (copay, coinsurance). Do not pay balance-billed amounts while the dispute is active.
- File a complaint if the provider refuses. File at cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.
- For uninsured disputes (good faith estimate): Initiate the patient-provider dispute resolution process at cms.gov/nosurprises within 120 days.
7. Real examples of No Surprises Act protections
Example 1: Out-of-network anesthesiologist at in-network surgery center
A patient had outpatient knee surgery at an in-network surgery center. The anesthesiologist was out-of-network and billed $4,200 for general anesthesia (CPT 01382). Under the NSA, the patient’s cost-sharing was recalculated at in-network rates—a $60 copay instead of the $3,200 balance bill they initially received. Savings: $3,140.
Example 2: ER visit with out-of-network radiologist
A patient went to an in-network ER for a fall and had a CT scan. The ER doctor was in-network, but the radiologist who read the CT was out-of-network. The radiologist billed $1,100 for the CT interpretation (CPT 74178-26). The patient’s insurer initially processed it as out-of-network. After citing the NSA, it was reprocessed at in-network rates. The patient owed only their $40 copay. Savings: $870.
Example 3: Good faith estimate exceeded by $1,600
An uninsured patient received a good faith estimate of $2,400 for an outpatient MRI. The final bill was $4,000—$1,600 over the estimate. The patient filed a dispute through the patient-provider dispute resolution process. The independent reviewer determined the reasonable charge was $2,700. Savings: $1,300.
Frequently asked questions
What is the No Surprises Act?
The No Surprises Act is a federal law effective January 1, 2022, that protects patients from surprise medical bills in emergency situations and from out-of-network providers at in-network facilities. You can only be charged in-network cost-sharing rates in these situations.
Does the No Surprises Act apply to me if I have insurance?
Yes, if you have private health insurance (employer, marketplace, or individual plan). It does not apply to Medicare, Medicaid, TRICARE, or VA benefits, which have their own protections. Uninsured patients receive separate protections including the right to good faith estimates.
What should I do if I receive a surprise bill?
Contact your insurance company and the provider’s billing department. Cite the No Surprises Act and request the bill be reprocessed at in-network rates. If they refuse, file a complaint at cms.gov/nosurprises or call 1-800-985-3059. Our dispute guide has detailed templates.
What is a good faith estimate under the No Surprises Act?
A written estimate of expected charges that healthcare providers must give uninsured or self-pay patients before scheduled services. If the final bill exceeds the estimate by $400 or more, you can dispute it within 120 days through the patient-provider dispute resolution process.
Does the No Surprises Act cover ground ambulance bills?
No. Ground ambulance services are currently exempt. Air ambulance services are covered—you cannot be surprise-billed by an out-of-network air ambulance provider. Ground ambulance billing remains one of the most common sources of surprise bills.
Sources
- CMS: No Surprises Act — Overview and Consumer Resources
- CMS: Good Faith Estimates for Uninsured Patients
- No Surprises Act (Consolidated Appropriations Act, 2021) — Full Text
- KFF: No Surprises Act Implementation — What to Know
- Health Affairs: The No Surprises Act, Impact Analysis
- CMS: Independent Dispute Resolution (IDR) Process Guidance