The No Surprises Act: What It Means for Your Medical Bills (2025 Update)

What Is the No Surprises Act?

If you have ever received a medical bill that was far higher than expected - especially from a doctor or provider you did not choose - you are not alone. For years, surprise medical bills were one of the most feared consequences of seeking healthcare in the United States. A patient could walk into an in-network hospital, be treated by an out-of-network anesthesiologist or radiologist they never selected, and then receive a bill for thousands of dollars that their insurance refused to cover.

The No Surprises Act (NSA), signed into law as part of the Consolidated Appropriations Act of 2021 and effective January 1, 2022, was designed to end this practice. The law establishes federal protections against surprise, or “balance,” billing in specific healthcare scenarios. It applies to most Americans with private health insurance, including employer-sponsored plans and marketplace plans purchased through the Affordable Care Act, as well as uninsured and self-pay patients who are entitled to Good Faith Estimates before receiving care. For a full overview of your rights under this and related laws, visit our Know Your Rights hub.

The law is administered jointly by the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury. Understanding your rights under this law can save you hundreds or even thousands of dollars - and NilesAI is built to help you identify when those rights apply to your bills.

The Four Key Protections

The No Surprises Act creates four distinct categories of patient protection. Each addresses a different scenario where patients historically faced unexpected charges. Understanding which protection applies to your situation is the first step in challenging a bill that may violate the law.

1. Emergency Services

Under the No Surprises Act, emergency services are protected regardless of whether the facility or the treating providers are in your insurance network. This means that if you go to an emergency room - or are taken to one - you cannot be balance billed for the care you receive. Your insurer must cover the services as if they were in-network, and the provider and insurer must resolve any payment disagreements between themselves, not at your expense.

This protection covers the full scope of emergency care, including screening, stabilization, and any post-stabilization services provided before you can be safely transferred or discharged. According to the Office of the Assistant Secretary for Planning and Evaluation (ASPE), approximately 1 in 5 emergency department visits previously resulted in a surprise out-of-network bill - a problem the NSA was specifically designed to eliminate.

Your cost-sharing (copays, coinsurance, deductibles) for emergency services must be calculated based on in-network rates, even if the provider is out of network. This is a critical distinction: you still owe your normal in-network cost-sharing, but the provider cannot charge you the difference between their billed amount and what your insurer pays.

2. Non-Emergency Services at In-Network Facilities

One of the most common surprise billing scenarios occurs when a patient schedules a procedure at an in-network hospital, only to discover that the surgeon, anesthesiologist, pathologist, or other specialist involved was out of network. Under the No Surprises Act, out-of-network providers who deliver non-emergency services at an in-network facility cannot balance bill you for their services.

This protection covers a wide range of providers, including anesthesiologists, assistant surgeons, hospitalists, intensivists, neonatologists, pathologists, radiologists, and diagnostic service providers. According to HHS, these “ancillary” out-of-network providers were responsible for the majority of surprise bills before the law took effect.

There is an important exception: providers can ask you to waive your protections by signing a written consent form at least 72 hours before a scheduled procedure (or on the day of care for same-day scheduling). If you sign this consent, the provider may balance bill you. However, consent cannot be required as a condition of receiving care, and it does not apply to emergency services or ancillary providers like anesthesiologists and radiologists who you typically cannot choose.

3. Air Ambulance Services

Air ambulance transport is one of the most expensive healthcare services in the country, with average charges exceeding $40,000 per transport. Before the No Surprises Act, patients who were airlifted - often while unconscious or in critical condition - frequently received massive bills from out-of-network air ambulance providers. The NSA prohibits air ambulance providers from balance billing patients who have private insurance. Your cost-sharing must be calculated at in-network rates, and the provider and insurer must settle any payment disagreement through the Independent Dispute Resolution (IDR) process.

4. Good Faith Estimates for Uninsured and Self-Pay Patients

If you do not have insurance or choose to pay out of pocket, the No Surprises Act gives you the right to a Good Faith Estimate (GFE) of expected charges before you receive scheduled healthcare services. Healthcare providers and facilities must provide this estimate when you schedule care or when you request one.

The Good Faith Estimate must include the expected charges for the primary service as well as any reasonably expected associated items and services, such as lab tests, anesthesia, imaging, and facility fees. If the final bill exceeds the Good Faith Estimate by $400 or more, you have the right to dispute the charges through a patient-provider dispute resolution process administered by CMS. Our Good Faith Estimate guide walks through exactly how to request one, what it must contain, and how to file a dispute if your final bill exceeds it.

This protection is particularly important for the roughly 27 million uninsured Americans, as well as insured patients who choose to self-pay for certain services. As our guide on how to review a medical bill explains, understanding what you should owe before you receive care is one of the most powerful tools for avoiding overcharges.

What the No Surprises Act Does Not Cover

Despite its sweeping protections, the No Surprises Act has significant gaps that every patient should understand. Knowing what the law does not cover is just as important as knowing what it does, because these gaps represent areas where you remain financially vulnerable.

Ground Ambulance Services

The single largest gap in the No Surprises Act is its exclusion of ground ambulance services. Unlike air ambulances, ground ambulances are not subject to the federal balance billing ban. This is a major oversight given that ground ambulance services are overwhelmingly the more common form of emergency transport. Research from the Georgetown University Health Policy Institute has found that surprise bills from ground ambulance providers average between $450 and $1,200, with some exceeding $8,000.

Congress recognized this gap and established a federal advisory committee to study ground ambulance billing practices and recommend potential reforms. As of 2025, no federal legislation has been enacted to close this gap, though several states have implemented their own protections.

Other Exclusions

Beyond ground ambulances, the No Surprises Act does not apply to several other situations:

• Elective out-of-network care: If you knowingly choose an out-of-network provider and do not receive a consent waiver, the law does not prevent balance billing. The assumption is that you made an informed choice.
• Post-stabilization services with consent: After you are stabilized in an emergency setting, a facility may ask you to consent to continued out-of-network treatment. If you sign, you lose your balance billing protections for subsequent services.
• Short-term and limited-duration health plans: These plans, which are sometimes marketed as alternatives to ACA-compliant coverage, are generally not subject to the No Surprises Act.
• Federal health programs: Medicare, Medicaid, TRICARE, and VA benefits have their own billing rules and are not governed by the NSA (though Medicare already prohibits balance billing in most circumstances).

For a deeper analysis of how surprise billing intersects with overall medical debt, see our guide on medical debt in America.

The Independent Dispute Resolution (IDR) Process

When a patient is protected from balance billing under the No Surprises Act, the question of how much the insurer must pay the out-of-network provider is resolved through an Independent Dispute Resolution (IDR) process - sometimes called “baseball-style arbitration.” Both the provider and the insurer submit their proposed payment amounts to a certified IDR entity, which selects one of the two offers.

The IDR process has become one of the most contested aspects of the law. Its volume has far exceeded initial projections, and its outcomes have significant implications for healthcare costs.

According to data from America’s Health Insurance Plans (AHIP), more than 1.4 million disputes were filed through the IDR process in 2024, representing a 115% increase over the previous year. The system has been strained by this volume, leading to significant backlogs and processing delays.

Critically, approximately 40% of disputes filed have been found ineligible - often because the claim did not meet the requirements for NSA protections, the wrong forms were submitted, or the required open negotiation period was not completed. Additionally, providers in many disputes have submitted charges that are 400% or more above the median contracted rate, contributing to concerns that some providers may be using the IDR process to secure above-market reimbursements.

The CMS dispute resolution portal provides detailed guidance on the IDR process, including timelines, eligibility requirements, and how decisions are made. For patients, the key takeaway is that the IDR process happens between the provider and the insurer - you should not be receiving bills while a dispute is pending.

Good Faith Estimates: What You Need to Know

The Good Faith Estimate provision of the No Surprises Act is one of its most practical consumer tools, yet many patients are unaware it exists. Here is what you are entitled to and how to use it.

When you are entitled to a GFE:

• Whenever you schedule a healthcare service and you are uninsured or plan to self-pay
• Whenever you request one from a healthcare provider or facility
• The provider must deliver the estimate within specified timeframes: 1 business day for services scheduled at least 3 days in advance, or 3 business days for services scheduled at least 10 days in advance

What the GFE must include:

• Expected charges for the primary service
• Expected charges for all reasonably anticipated associated services (labs, imaging, anesthesia, facility fees)
• Provider and facility identifying information (name, NPI, TIN)
• Diagnosis codes and service codes

The $400 threshold: If your final bill exceeds the Good Faith Estimate by $400 or more, you have the right to initiate a patient-provider dispute resolution process. This is a formal process separate from the IDR process described above, and it is designed specifically for uninsured and self-pay patients. The dispute is reviewed by an independent third party, and the outcome is binding.

For additional context on how to interpret the charges on your bill, our guide to understanding your Explanation of Benefits (EOB) walks through each line item and what it means.

State Surprise Billing Laws: Some States Go Further

The No Surprises Act establishes a federal floor for surprise billing protections, but many states had enacted their own laws before the federal law took effect - and some of those state laws provide stronger protections. According to research from the Commonwealth Fund and the National Academy for State Health Policy (NASHP), the system varies significantly across the country.

State	Protection Level	Notable Feature
California	Stronger than federal	Covers ground ambulances; applies to all state-regulated plans
Colorado	Stronger than federal	Protects against ground ambulance balance billing
Florida	Stronger than federal	Covers emergency and non-emergency surprise bills with payment standard
Illinois	Stronger than federal	Ground ambulance protections; broad provider coverage
New York	Stronger than federal	One of the first states to ban surprise billing (2015); covers ground ambulances
Ohio	Federal standard	Relies primarily on federal NSA protections
Oregon	Stronger than federal	Complete protections including ground ambulance
Texas	Stronger than federal	Covers emergency and non-emergency; independent arbitration since 2020
Virginia	Stronger than federal	Covers ground ambulances; applies to fully insured plans
Wyoming	Federal standard	Relies primarily on federal NSA protections

state laws generally apply only to state-regulated insurance plans (typically fully insured plans purchased by individuals or small employers). Self-funded employer plans - which cover the majority of workers at large companies - are regulated under federal ERISA law and are subject only to the federal No Surprises Act. If you are unsure which type of plan you have, your HR department or insurance card should be able to clarify.

For patients in states with stronger protections, particularly those covering ground ambulance services, the combination of state and federal law provides a more complete safety net. Use our State Balance Billing Lookup tool to quickly find the specific rules and contact for your state’s insurance regulator.

How to Use the No Surprises Act to Fight Unfair Charges

If you have received a medical bill that you believe violates the No Surprises Act, you have concrete steps you can take to challenge it. Here is a step-by-step process for exercising your rights.

The Consumer Financial Protection Bureau (CFPB) also accepts complaints related to medical billing and debt collection practices, particularly if a provider sends a disputed bill to collections. Filing complaints with multiple agencies can increase pressure on providers to resolve billing issues.

Understanding your rights under the No Surprises Act is powerful, but working through the details - identifying which protections apply, verifying whether charges are in-network or out-of-network, and calculating whether a Good Faith Estimate was exceeded - can be time-consuming and confusing. This is especially true when you are dealing with multiple bills from multiple providers for a single episode of care, which is common after emergency room visits and hospital stays. For a breakdown of how emergency room costs are structured, see our guide to emergency room costs.

How NilesAI Helps You Use the No Surprises Act

NilesAI is purpose-built to help patients and their advocates identify billing errors, overcharges, and potential violations of laws like the No Surprises Act. When you upload a medical bill or EOB to NilesAI, our AI-powered scan engines automatically check for:

• Out-of-network charges in emergency settings that should be billed at in-network rates under the NSA
• Balance billing by ancillary providers at in-network facilities that may violate federal or state law
• Good Faith Estimate discrepancies where the final bill exceeds the pre-service estimate by $400 or more
• Billing errors and overcharges including upcoding, duplicate charges, and unbundling violations - which our medical billing errors whitepaper documents in detail

Rather than spending hours cross-referencing bills, EOBs, provider directories, and legal requirements, NilesAI does the analysis in seconds and flags the specific issues that may entitle you to a reduced bill or a formal dispute.

If you are dealing with a medical bill that does not look right - whether it is a surprise bill from an out-of-network provider, a charge that exceeds your Good Faith Estimate, or simply a number that seems too high - NilesAI can help you understand what you owe, what you do not, and what your next steps should be.

Ready to check your bill? Upload your medical bill or EOB to NilesAI and let our AI find the errors and protections that apply to you. Get started with NilesAI today.

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