Patients can receive care at an in-network facility and still encounter an out-of-network provider they did not choose. Historically, that situation sometimes resulted in unexpected medical bills.
The federal No Surprises Act created protections designed to reduce many of these bills and change how certain out-of-network claims and payment disputes are handled. People frequently search for the “no surprise billing act,” but the federal law is officially known as the No Surprises Act.
For providers, the law is not only a patient billing issue. It also affects claim workflows, cost sharing, notices, payment disputes, and revenue-cycle operations. Our hospital revenue cycle services connect these requirements to claims, payment posting, denial review, patient billing, and A/R follow-up.
What is the No Surprises Act?
The No Surprises Act was enacted as part of the Consolidated Appropriations Act, 2021. Major consumer protections took effect on January 1, 2022.
CMS explains that the protections apply in many situations involving emergency services, certain non-emergency services, and air ambulance services when out-of-network care is involved. In covered situations, the patient generally cannot be charged more than the applicable in-network cost-sharing amount simply because the provider was out of network.
Why surprise billing occurs
A patient may carefully select an in-network hospital but receive care from an out-of-network clinician working at that facility. Emergency situations create another problem because patients usually cannot evaluate network status before treatment.
Before federal protections took effect, an out-of-network provider could in some situations bill the patient for the difference between the billed charge and the health plan’s payment. This is commonly called balance billing. An unexpected balance bill is commonly described as a surprise bill.
Which services receive federal protections?
Federal protections apply to many emergency services provided by out-of-network providers or facilities when the patient’s plan covers emergency care. They also apply to certain non-emergency services delivered by out-of-network providers at in-network facilities. Air ambulance services receive important protections as well.
The rules are detailed, and providers need to determine whether a particular service and coverage arrangement falls within the applicable federal requirements. State laws can also provide additional protections.
Ground ambulance services are an important exception
Ground ambulance services are generally not covered by the federal No Surprises Act balance-billing protections, although state laws may provide separate protections. Air ambulance services are treated differently and can fall within federal protections.
This distinction is important for patient financial services and ambulance billing teams. A broad policy that treats every ambulance claim the same way can create billing errors.
What the No Surprises Act changes for providers
For revenue-cycle teams, compliance begins with identifying claims that may be subject to the law. The billing system needs accurate information about payer network status, facility status, service type, and the circumstances of care.
When a protected claim is identified, the provider must follow applicable patient cost-sharing and balance-billing requirements. The organization may also need to manage required notices and disclosures. A mistake during this process can become a patient complaint, refund issue, compliance concern, or payment dispute.
These claims should be managed as part of the broader medical billing workflow so that patient responsibility is not assigned until the payer’s processing and applicable protections have been reviewed.
The federal independent dispute resolution process
The No Surprises Act established a federal independent dispute resolution process for certain disagreements between payers and providers regarding out-of-network payment. CMS maintains a dedicated Federal IDR and No Surprises resource center for providers, facilities, plans, issuers, and consumers.
The patient is generally removed from the payment dispute in situations subject to these protections. Revenue-cycle teams should track notices, deadlines, payer communications, and supporting claim information carefully because a missed procedural requirement can affect the dispute pathway.
Why remittance and documentation matter
Payment disputes depend on more than the billed charge. The provider’s claim information, service details, network status, notices, payer response, and applicable deadlines can all matter.
CMS also publishes No Surprises Act information under the Consolidated Appropriations Act, 2021, including information about the qualifying payment amount and remittance advice remark code requirements used in certain claims communications.
Revenue-cycle teams should preserve the information needed to support the claim and any later dispute process. Poor documentation makes it harder to reconstruct what happened when a claim reaches escalation.
The connection with denial management
A No Surprises Act claim can touch several revenue-cycle functions. The payer may issue an initial payment or deny payment. The organization then needs to determine whether the claim was processed correctly, whether the service falls under the applicable protections, and what dispute options are available.
That evaluation belongs within a structured denial management process that reviews the payer response, identifies the appropriate next action, and tracks deadlines instead of simply rebilling the account.
How providers can reduce billing problems
The no surprise billing act should not be treated as a single compliance checklist. It affects patient access, contracting information, claim submission, payment posting, patient statements, and dispute management.
Claims subject to surprise-billing protections should be identified early, and the information should remain visible through final account resolution. When patient access, billing, and payment teams work from different information, a protected patient can receive the wrong bill or a valid payment issue can remain unresolved.
Frequently asked questions
Is the No Surprises Act the same as the no surprise billing act?
The official federal name is the No Surprises Act. “No surprise billing act” is a common search phrase used to describe the same subject.
Does the No Surprises Act cover emergency care?
It provides protections against certain unexpected out-of-network charges for emergency services when applicable requirements are met.
Does it cover air ambulance services?
Federal protections can apply to out-of-network air ambulance services.
Does it cover ground ambulance services?
Ground ambulance services are generally not covered by the federal No Surprises Act protections, although state protections may apply.
Can providers dispute an out-of-network payment?
Certain eligible disputes can use the Federal IDR process when applicable requirements and timelines are met.