How to Use the No Surprises Act to Fight Unexpected Medical Bills

The No Surprises Act (NSA), codified at 42 U.S.C. §§ 300gg-111 and 300gg-112, took full effect on January 1, 2022 and represents one of the most significant consumer protections in American healthcare in decades. It protects you from balance billing — the practice of out-of-network providers billing you for the difference between their charge and what your insurance paid — in situations where you had no realistic opportunity to choose an in-network provider. Before the NSA, approximately 1 in 5 emergency room visits and 1 in 6 in-network hospital stays resulted in a surprise out-of-network bill according to Peterson-KFF Health System Tracker research.

Why Insurers and Providers Deny NSA Protections

The NSA does not automatically apply — insurers and providers frequently misapply it, ignore it, or attempt to use waiver arguments to circumvent it. The most common scenarios where you should invoke the NSA:

• Emergency room visit at an in-network hospital where the treating physician was out-of-network — The NSA explicitly prohibits balance billing in this scenario regardless of provider network status
• Scheduled surgery at an in-network facility where the anesthesiologist or assistant surgeon was out-of-network — These ancillary providers cannot balance bill when you chose an in-network facility
• In-network hospital stay where a consulting specialist (radiologist, pathologist, hospitalist) was out-of-network — You had no opportunity to choose these providers
• Air ambulance services from out-of-network providers — Covered by NSA; ground ambulance is the notable gap
• Insurer processed the claim at out-of-network rates despite NSA protections applying — Your cost-sharing must be calculated at in-network rates

How to Dispute a No Surprises Act Violation

eob-against-the-bill">Step 1: Obtain and Compare Your EOB Against the Bill

Request your Explanation of Benefits from the insurer for the date of service. Compare how the claim was processed: did the insurer apply in-network cost-sharing or out-of-network cost-sharing? Did the provider bill you for more than your stated in-network cost-sharing obligation? Under the NSA, your copay, coinsurance, and deductible must be calculated as if the provider were in-network, and these amounts count toward your in-network out-of-pocket maximum.

Step 2: Contact Your Insurer to Demand Reprocessing

Call the member services number on your insurance card and use this script: "I am calling to dispute the processing of claim [number] for services on [date] at [facility]. This service is subject to the No Surprises Act because [it was emergency care / the provider was out-of-network at an in-network facility and I did not have an opportunity to select an in-network provider]. Under 42 U.S.C. § 300gg-111, my cost-sharing must be calculated at in-network rates. I am requesting reprocessing of this claim." Document the date, representative's name, and all reference numbers.

Step 3: Contact the Provider in Writing

Send a written letter to the provider's billing department: "I received a bill for $[amount] for services on [date] at [facility]. Under the No Surprises Act (42 U.S.C. § 300gg-112), you are prohibited from balance billing me for this service. My maximum liability is my in-network cost-sharing amount as determined by [insurer]. Please adjust this bill to reflect my in-network cost-sharing obligation. Providers who knowingly violate the NSA face penalties of up to $10,000 per violation under CMS enforcement authority."

Step 4: Follow Up All Phone Calls in Writing

Every phone conversation should be followed by a written summary referencing the specific NSA provision: "This letter confirms our conversation on [date] with [representative], during which I disputed this bill under the No Surprises Act, Public Law 116-260 and 42 U.S.C. §§ 300gg-111 and 300gg-112."

Step 5: File a Federal Complaint With the No Surprises Help Desk

File with CMS at 1-800-985-3059 or at cms.gov/nosurprises. The federal No Surprises Help Desk handles complaints against both insurers and providers. Filing a complaint creates a formal record and initiates CMS oversight of the specific violation.

Step 6: Escalate to State Regulators and Challenge Improper Waivers

File a complaint with your state department of insurance for state-level enforcement. If a provider claims you signed a consent waiver, challenge its validity: the NSA requires that waivers be provided at least 72 hours before the service (or at scheduling if less than 72 hours), clearly state the provider is out-of-network, include a good faith cost estimate, and be signed voluntarily — it cannot be a condition of receiving care. Emergency services and ancillary specialists (anesthesiology, radiology, pathology) cannot be waived under any circumstances. A waiver signed in an emergency room waiting room under duress is challengeable.

What to Include in Your Appeal

• Original medical bill showing the balance-billed amount and the services rendered
• Explanation of Benefits showing how the insurer processed the claim (in-network vs. out-of-network rates)
• Documentation confirming the facility was in-network at the time of service
• Documentation that you did not voluntarily select the out-of-network provider
• Evidence that no valid consent waiver was signed (or grounds for challenging the waiver's validity)
• Written record of all communications with insurer and provider: dates, names, reference numbers
• CMS complaint reference number after filing with the No Surprises Help Desk

Fight Back With ClaimBack

If your insurer is not properly applying No Surprises Act protections, or if you are facing a balance bill for a service that should be subject to NSA protections, ClaimBack helps you identify the applicable statutory provisions and generate a professional dispute letter for both the insurer and the provider. ClaimBack generates a professional appeal letter in 3 minutes.

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Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal