What Is the No Surprises Act

The No Surprises Act (NSA), effective January 1, 2022, is a federal law that protects patients with job-based or individual market coverage from surprise balance bills for emergency services and for services furnished by out-of-network providers at in-network facilities. It generally prohibits out-of-network providers from balance billing patients in protected situations, establishes a federal independent dispute resolution process for payment disagreements between providers and payers, and requires Good Faith Estimates for uninsured or self-pay patients.

Before the NSA, a patient could receive care at an in-network hospital and still receive a large balance bill from an out-of-network anesthesiologist, radiologist, or lab they did not choose. The law addresses that gap by shifting the payment dispute from the patient to a federal process between the provider and the payer, and by requiring price transparency for self-pay patients through Good Faith Estimates.

Identify protected situations before billing. The NSA applies to emergency services from out-of-network facilities and providers, and to non-emergency services furnished by out-of-network providers at in-network facilities. A balance bill in a protected situation is generally prohibited; one outside the protections may still be permissible, so the first step is determining which applies.

Issue the required patient notices. The law requires specific notices to be provided to patients in certain situations, including a consent notice for out-of-network services at in-network facilities where the patient voluntarily chooses out-of-network care. The notice content and timing are prescribed, not discretionary.

Route payment disputes to the federal IDR process. When a provider and payer disagree on the payment amount for a service covered by the NSA's balance-billing protections, they use the federal independent dispute resolution process rather than billing the patient. The patient's cost-sharing is limited to the in-network amount.

Provide Good Faith Estimates to self-pay patients. The NSA requires providers to furnish written estimates of expected charges to uninsured and self-pay patients for scheduled services, within specified timeframes. Patients may dispute bills that exceed the estimate beyond a defined threshold.

Document compliance at each step. The law's requirements are enforceable, and CMS investigates complaints. Keeping records of notices provided, estimates furnished, and IDR submissions is part of compliance, not just good practice.

• A process to flag claims that fall under NSA protections before patient billing begins.
• Standardized NSA notice templates that match current CMS guidance.
• A tracking system for Good Faith Estimates furnished, including dates and content.
• A workflow for the patient-provider dispute resolution process when bills exceed estimates.
• A training program so front-desk, billing, and clinical staff recognize NSA-protected situations.

1. 01

   Determine whether the service falls under NSA protections

   Before billing a patient for out-of-network charges, confirm whether the service was emergency care or was furnished by an out-of-network provider at an in-network facility. If either applies, balance billing is generally prohibited.
2. 02

   Provide required notices

   If the patient is receiving non-emergency services from an out-of-network provider at an in-network facility and may consent to out-of-network care, provide the NSA consent notice using the prescribed content and timing. Document that the notice was given.
3. 03

   Limit patient cost-sharing to the in-network amount

   In protected situations, the patient's cost-sharing is calculated as if the provider were in-network. Apply the in-network deductible, coinsurance, and copayment rather than the out-of-network amounts.
4. 04

   Initiate the federal IDR process if needed

   If the payer's payment amount is disputed, the provider and payer use the federal independent dispute resolution process. The patient is not part of this process and should not be billed while it is pending.
5. 05

   Furnish Good Faith Estimates for self-pay patients

   For scheduled services to uninsured or self-pay patients, provide a written Good Faith Estimate within the required timeframe. Retain the estimate and be prepared to operate the dispute resolution process if the final bill exceeds it.

Review the control on a fixed cadence and after a material policy, payer, system, staffing, or workflow change. Compare the current process with its documented design, sample the evidence it produces, and record exceptions separately from completed routine work. A control that exists only in a policy but leaves no observable evidence cannot be evaluated reliably.

Use findings to change the upstream process, not merely to clear the current queue. Assign one owner, one next action, and one follow-up date. Preserve the definition and baseline used for the review so a later result can be compared without changing the measurement after the fact.