The No Surprises Act took effect on January 1, 2022. It targets the bill that used to arrive weeks after a hospital visit from a doctor you never chose: the anesthesiologist, the emergency physician, the radiologist, working at your in-network hospital but not in your network, billing you the difference between their charge and what your insurer paid. That practice, called balance billing, is now illegal in most of the situations where it used to happen. The law also created rights for people without insurance.
What it protects insured patients from
If you have insurance, the law says you cannot be billed more than your in-network cost-sharing (copay, coinsurance, deductible) for:
- Emergency care, at any hospital or freestanding emergency department, in or out of network, including the care you get after you are stabilized until you can be safely moved.
- Non-emergency care at an in-network hospital or surgery center from an out-of-network provider: anesthesiologists, radiologists, pathologists, assistant surgeons, hospitalists, laboratory services. These are the providers you do not pick.
- Air ambulance transport.
The provider and your insurer settle the rest between themselves, through negotiation or a federal arbitration process. Your bill is the same as if everyone had been in network.
What it does not cover
- Ground ambulances, which were left out and remain a common surprise.
- Out-of-network providers you chose, such as a surgeon you picked who is not in your plan. Some of these providers can ask you to sign a notice-and-consent waiver at least 72 hours before a scheduled service; if you sign, you give up the protection for that service. You cannot be asked to sign one for emergency care or for the ancillary providers listed above.
- Care at an out-of-network hospital for a scheduled procedure.
- Plans not subject to the law, mainly some short-term plans and health-sharing ministries.
What it gives uninsured and self-pay patients
This is the part that matters most for people using price files. If you do not have insurance, or you have it but choose not to use it, any provider or facility must give you a good faith estimate of the expected charges, in writing, before a scheduled service:
- Within 3 business days of scheduling if the service is 10 or more days away, or within 1 business day if it is 3 to 9 days away.
- On request at any time, even if you have not scheduled.
- Listing the expected services by code with their charges, and the charges expected from other providers involved (the surgeon, anesthesia) where they are part of the same episode.
If the final bill is $400 or more above the estimate, you can start a patient-provider dispute resolution process through the federal government within 120 days of the bill. An independent reviewer decides whether the extra charges were justified, for a fee of $25. While the dispute is open the provider cannot send the bill to collections.
How to use it
- When scheduling, say: "I will be self-pay. Please send me a good faith estimate for this procedure with the codes and the charges from all providers involved."
- Compare the estimate's facility line with the hospital's published cash price for the code. If the estimate is higher, ask why before the service.
- Keep the estimate. After the service, compare the itemized bill line by line.
- If the bill is $400 or more over the estimate, file a dispute at cms.gov/nosurprises within 120 days.
If you are insured and get a bill from an out-of-network provider at an in-network hospital, do not pay it. Call your insurer, cite the No Surprises Act, and ask them to reprocess the claim at in-network cost-sharing. If the provider keeps billing, complaints go to the same federal office; there are penalties of up to $10,000 per violation.
Where the price files fit
The published cash price is the number you hold the good faith estimate against. A hospital that publishes a cash price of $1,480 for a colonoscopy and sends an estimate of $3,000 has some explaining to do, and the law gives you the standing to ask.