The No Surprises Act: What You Need to Know

Update (3/1/2022): The enforcement of the NSA is pending ongoing legislation and potentially adjusted rule provisions. HealthMark continues to remain apprised of changes and will provide ongoing updates.


Surprise medical billing, particularly around a patient receiving care from an out-of-network provider at an in-network facility (i.e. non “shopped” services – think: the anesthesiologist whom you have never met at the facility where you are receiving a knee replacement), has been a long-debated poor outcome in our healthcare environment.

Congress has recently passed the No Surprises Act (NSA), designed to protect patients from unexpected – surprise – medical bills. In an era of increased access to care and efforts to improve coordination among providers, this law was seen as potentially a dramatic step forward towards better transparency within our healthcare system. As with any regulatory change, full implementation takes time, and it takes rulemaking beyond just the act itself. The rulemaking process that followed the passage of the bill has been controversial and the interim final rule proposed in September of 2021 continues to receive scrutiny. Let’s break it down:


  • Approximately one in five patients receive surprise medical bills
  • Average costs of unexpected medical bills range from $750 to $2,600 per incident1
  • The government estimates 39.7 million annual emergency visits by patients with private insurance, of which 7.1 million visits involve at least one out-of-network claim2
  • Out-of-network billing raises the cost of specialty physician care for employer-sponsored health insurance by $40 billion3
  • Out-of-network air ambulances can lead to unexpected bills of up to six figures4


  • The American Medical Association and American Health Association filed a lawsuit in December 2021 for declaratory relief alleging that the interim final rule issued by the Departments (DHS, Labor, Treasury, and OPM) violated or exceeded the Departments’ statutory authority; this litigation could result in a delay in either enforcement or application of the rule
  • The rule attempts to ban surprise bills, including for emergency services, out-of-network cost-sharing, and out-of-network balance bills for supplemental services
  • The act mandates that where patients did not have the ability to consent to out-of-network care (as in the case of certain emergent care), there are limits on the ability of the facility or provider to bill in excess of in-network cost sharing arrangements
  • Requirements now exist for notice-and-consent when care is delivered by out-of-network providers at in-network facilities
  • Covered providers must supply easy-to-understand good faith estimates for self-pay and uninsured patients prior to non-emergent treatment
  • Final bills that exceed estimates by $400 may be disputed within 120 days of the bill date5
  • Disputed bills can be subject to a “baseball style” arbitration process where providers and insurers submit best and final offers for the amount each side considers reasonable for final payment
  • Surprise billing does not occur in government-sponsored programs like Medicare, Medicaid, and veterans’ care (since these groups pay fixed fees to providers)
  • Enforcement mechanisms and procedures are still unclear, but a penalty of up to $10,000 for each violation of billing outside the cost-share amount may apply6

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