What Is Surprise Billing? (And How the No Surprises Act Protects You)

What Is Surprise Billing?

Surprise billing occurs when you receive an unexpectedly high medical bill — typically from an out-of-network provider — after receiving care at an in-network facility or in a situation where you had no realistic ability to choose your provider. The bill is a "surprise" because you expected your in-network costs to apply.

Surprise bills most commonly arise in emergency situations, during planned surgeries where out-of-network specialists (such as anesthesiologists or radiologists) are involved without your knowledge, or when an in-network hospital uses out-of-network providers as part of your care team.

When Does Surprise Billing Happen?

Common scenarios include:

Emergency care: You are transported to or treated at the nearest emergency room, which may be out-of-network. You had no choice in the matter.

Facility vs. provider mismatch: You choose an in-network hospital, but the surgeon, anesthesiologist, assistant surgeon, or radiologist who treats you is not in your plan's network — even though they practice at your in-network hospital.

Air ambulance transport: You are transported by air ambulance (helicopter or fixed-wing) and the transport company is not in your plan's network.

Lab and radiology services: Blood work or imaging ordered during an in-network visit is processed by an out-of-network laboratory or radiology group.

What Is the No Surprises Act?

The No Surprises Act (NSA) is a federal law that took effect on January 1, 2022, providing nationwide protections against surprise medical bills. The law applies to most privately insured individuals, including those with employer-sponsored plans, individual and family plans through the ACA marketplace, and grandfathered group health plans.

Key protections under the No Surprises Act:

1. Limits on out-of-network charges for emergency care For emergency services, out-of-network providers can only bill you your in-network cost-sharing amount (your copay, coinsurance, and deductible). They cannot bill you the difference between their charge and your insurer's payment — a practice previously called balance billing.

2. Limits on out-of-network charges at in-network facilities If you receive non-emergency care at an in-network facility from an out-of-network provider (such as a specialist you did not choose), the provider is generally limited to charging your in-network cost-sharing amount.

3. Air ambulance protections The NSA extends protections to ground and air ambulance services, limiting out-of-network balance billing in most circumstances.

4. Advanced EOB)" class="auto-link">Explanation of Benefits Health plans must provide patients with an Explanation of Benefits before scheduled services, so you can understand your expected costs in advance.

5. Good Faith Cost Estimates Providers must provide good faith cost estimates before scheduled services, and if your final bill exceeds the estimate by $400 or more, you have the right to dispute it.

What Does the No Surprises Act NOT Cover?

The NSA has important limitations:

• It does not apply to ground ambulance services in most circumstances (a separate rulemaking is pending)
• It does not apply to services you voluntarily choose from an out-of-network provider after receiving proper notice and signing a written consent form
• It does not apply to self-pay or uninsured patients (though separate good faith estimate rules apply)
• It does not cover all situations involving out-of-network facilities — only out-of-network providers at in-network facilities or emergency situations

How Does the No Surprises Act Dispute Process Work?

If you receive a surprise bill in violation of the NSA:

Step 1: Dispute the bill with the provider. Contact the provider or facility and inform them that the No Surprises Act applies to your situation. Providers are legally prohibited from billing you more than your in-network cost-sharing amount in covered situations.

Step 2: Contact your insurer. Your insurer is responsible for enforcing the NSA protections on your behalf. File a complaint with your insurer if a provider is demanding an NSA-prohibited payment.

Step 3: Use the federal complaint process. File a complaint with the federal government at cms.gov/nosurprises or call 1-800-MEDICARE. The Centers for Medicare & Medicaid Services (CMS) investigates NSA violations and can impose civil monetary penalties on providers.

Step 4: File a state complaint. Many states have their own surprise billing laws — some more protective than the federal law. Your state insurance commissioner can investigate complaints against insurers; your state attorney general or health department may handle provider complaints.

What If Your Insurer Underpays After a Surprise Bill Situation?

The No Surprises Act also created an Independent Dispute Resolution (IDR) process — but this is designed for provider-insurer payment disputes, not patient billing disputes. As a patient, your primary protections are:

• You are only responsible for your in-network cost-sharing amount
• You cannot be balance billed for the difference

If your insurer is not applying these protections correctly — for example, if it is counting out-of-network surprise bills against your out-of-network deductible rather than your in-network deductible — you can appeal the insurer's determination.

Fight Back With ClaimBack

If you received a surprise bill you should not owe, or your insurer failed to apply the No Surprises Act protections, ClaimBack can help you build an appeal that correctly applies your legal protections.

Start your appeal at https://claimback.app/appeal.

Related Reading

• What Is Network Adequacy?
• What Is a Claim Denial? Types, Reasons, and What to Do
• What Is the Insurance Claim Appeal Process? Step-by-Step