No Surprises Act 2025: Everything You Need to Know

The No Surprises Act (NSA) has been in effect since January 1, 2022, and has fundamentally reshaped how surprise medical billing works in the United States. By 2025, the law has been tested in federal courts, updated through regulatory guidance, and increasingly enforced by CMS — making it more important than ever for patients to understand exactly how it works and when to invoke it.

Why Surprise Bills Still Happen Despite the Law

Emergency care out-of-network denials. Insurers still process some emergency claims applying out-of-network cost-sharing, contrary to the NSA. Under 42 U.S.C. § 300gg-111, emergency services must be covered at the in-network benefit level regardless of provider network status. If you receive an emergency bill with out-of-network cost sharing applied, this is likely an NSA violation.

Out-of-network providers at in-network facilities. The classic surprise billing scenario: you go to an in-network hospital but receive a bill from an out-of-network anesthesiologist, radiologist, or assistant surgeon. The NSA prohibits these providers from balance billing you. If you receive such a bill without having signed a proper advance consent, the provider may be violating federal law.

Air ambulance overbilling. Under NSA provisions for air ambulance services, out-of-network air ambulance providers cannot charge you more than your in-network cost-sharing amount. Ground ambulance remains a significant gap — it is excluded from federal NSA protections, though some states have enacted their own ground ambulance surprise billing protections.

Good Faith Estimate failures. For uninsured and self-pay patients, the NSA requires providers to furnish Good Faith Estimates before scheduled services. If your final bill exceeds the GFE by more than $400, you can initiate the Patient-Provider Dispute Resolution (PPDR) process through CMS.

Invalid consent forms. Providers sometimes ask patients to sign consent forms waiving NSA protections. These waivers are only valid under strict conditions: at least 72 hours' advance notice, written disclosure of the provider's out-of-network status and estimated charges, and the patient's right to choose an in-network alternative. The NSA explicitly prohibits consent waivers for emergency services and for ancillary providers like anesthesiologists, radiologists, and pathologists — consent obtained in these situations is invalid.

How to Appeal and Fight NSA Violations

Step 1: Identify Whether the NSA Applies

Determine which NSA category your situation falls into: emergency services (any facility), non-emergency services at an in-network facility by an out-of-network provider (without valid advance consent), or out-of-network air ambulance services. If your situation falls into one of these categories, the provider cannot legally balance bill you beyond your in-network cost-sharing.

Step 2: Review Your EOB)" class="auto-link">Explanation of Benefits

Your EOB from the insurer shows what was paid and how your cost-sharing was calculated. If the EOB applies out-of-network cost-sharing to an NSA-protected service, your insurer is not properly implementing the law. Contact your insurer and request reprocessing of the claim at in-network cost-sharing rates, citing 42 U.S.C. § 300gg-111.

Step 3: Contact the Provider Directly

Call the provider's billing department and inform them the bill is prohibited by the No Surprises Act. Request that they adjust the bill to reflect only your in-network cost-sharing amount. Reference the NSA statute and the prohibition on balance billing. Many providers comply immediately once the legal prohibition is cited.

Step 4: File a Federal NSA Complaint

If the provider or insurer does not comply, file a complaint with the CMS No Surprises Help Desk at 1-800-985-3059 or online at no-surprises.cms.gov. CMS investigates violations and can impose penalties of up to $10,000 per violation on providers who repeatedly violate the NSA.

Step 5: File a State Insurance Department Complaint

Many states had surprise billing laws before the federal NSA. California, New York, Texas, Colorado, Oregon, and Washington all have state-level protections that may be broader than the federal law. File a parallel complaint with your state department of insurance.

Step 6: Use the Patient-Provider Dispute Resolution Process

For uninsured or self-pay patients whose final bill exceeds the GFE by more than $400, submit a PPDR request through CMS. The dispute is adjudicated by a PPDR entity, and the decision is binding on the provider.

What to Include When Disputing a Surprise Bill

• Your EOB showing how the insurer processed the claim
• The provider's bill with the balance billing amount identified
• Documentation that you did not sign a valid advance consent for out-of-network charges
• Emergency department records if the NSA's emergency care provision applies
• Your state's insurance laws and any state-level surprise billing protections that supplement the federal NSA

Fight Back With ClaimBack

No Surprises Act violations — particularly balance billing by anesthesiologists, radiologists, and ER physicians at in-network facilities — are among the clearest-cut insurance disputes to resolve when you know the law and document the violation correctly. ClaimBack generates a professional appeal letter in 3 minutes. Start your free claim analysis → Free analysis · No credit card required · Takes 3 minutes

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• What Is Medical Necessity?
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