Compliance and Regulations
Federal laws and CMS requirements that shape how providers bill, what they must disclose to patients, and which balance bills are prohibited.
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What is medical billing compliance?
Medical billing compliance is the set of federal laws, regulations, and payer requirements that govern how a provider bills for care, what information must be disclosed to patients before service, and which charges are prohibited. It is not optional — the rules apply whether or not a practice is aware of them, and the penalties for noncompliance range from claim denials to federal enforcement.
The two regulatory areas that most directly affect day-to-day billing are the No Surprises Act, which restricts balance billing in emergency and facility-based settings and requires Good Faith Estimates for self-pay patients, and hospital price transparency, which requires hospitals to publish their standard charges. Both are CMS-enforced and both changed what billing teams must do before, during, and after a patient encounter.
Compliance is not a one-time setup. The rules are revised, the enforcement guidance evolves, and a practice that was compliant last year may not be this year. The articles in this category explain what each rule requires, who it applies to, and how to operationalize it in a billing workflow.
What to learn first
Start with the law that changed the most about how providers bill patients, then learn the estimate requirement it added, then the transparency rule that runs alongside it.
Understand the No Surprises Act
The federal law that prohibits surprise balance bills in emergency and facility-based settings and established the Good Faith Estimate requirement.
Read: What Is the No Surprises ActOperationalize Good Faith Estimates
How to produce, deliver, and document the written estimates the NSA requires for uninsured and self-pay patients.
Read: Good Faith Estimates for Self-Pay PatientsUnderstand hospital price transparency
The CMS requirement for hospitals to publish standard charges and how it intersects with patient estimates.
Read: Hospital Price Transparency
Key articles
What Is the No Surprises Act
The No Surprises Act is a federal law that protects patients from surprise balance bills in emergency and certain facility-based settings and requires Good Faith Estimates for self-pay patients.
Updated · 5 min readGood Faith Estimates for Self-Pay Patients
The No Surprises Act requires providers to furnish written estimates of expected charges to uninsured and self-pay patients for scheduled services, within specified timeframes.
Updated · 5 min readHospital Price Transparency
CMS requires hospitals to publish their standard charges — including gross charges, discounted cash prices, and payer-specific negotiated rates — in machine-readable and consumer-friendly formats.
Updated · 5 min readAll compliance and regulations articles
26 articles in this section.
Regulatory requirements8
- What Is the No Surprises Act5 min
- Good Faith Estimates for Self-Pay Patients5 min
- Hospital Price Transparency5 min
- The HIPAA Privacy Rule in Medical Billing9 min
- Applying the Minimum Necessary Standard in Medical Billing11 min
- Business Associate Agreements in Medical Billing14 min
- The HIPAA Security Rule in Medical Billing15 min
- The HIPAA Breach Notification Rule in Medical Billing14 min
More articles18
- The HIPAA Right of Access in Medical Billing15 min
- The Seven Elements of an Effective Compliance Program12 min
- OIG Exclusion Screening in Medical Billing13 min
- The Anti-Kickback Statute in Medical Billing13 min
- The Stark Law and Physician Self-Referral in Medical Billing15 min
- Waiving a Patient's Copay, Coinsurance, or Deductible14 min
- The 60-Day Overpayment Rule14 min
- The OIG Self-Disclosure Protocol12 min
- The Types of Medicare Audits16 min
- Responding to a Payer's Request for Medical Records15 min
- Medical Records Retention15 min
- The Information Blocking Rule16 min
- The No Surprises Act Independent Dispute Resolution Process19 min
- The No Surprises Act Notice and Consent Exception14 min
- The Transparency in Coverage Rule13 min
- The False Claims Act in Medical Billing16 min
- Running an Internal Billing Audit17 min
- Section 1557 of the Affordable Care Act12 min
Related glossary terms
Key regulatory and patient-protection terms that appear across these articles.
Authoritative sources
- 45 CFR § 149.110 — Preventing surprise medical bills for emergency services (opens in a new tab)
The balance-billing restriction this category exists to explain, in the emergency setting: what a plan or issuer must cover when it provides benefits for services in a hospital emergency department or an independent freestanding emergency department.
- 45 CFR § 149.610 — Good faith estimates for uninsured (or self-pay) individuals (opens in a new tab)
The Good Faith Estimate requirement itself: what providers and facilities must issue, to whom, and on what trigger — on request, or on scheduling an item or service.
- 45 CFR § 180.50 — Requirements for making public hospital standard charges (opens in a new tab)
The hospital price transparency rule, including the requirement that each location operating under a single hospital license with a different set of standard charges publish its own list.
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