Surprise billing

Surprise billing — out-of-network charges at an in-network facility

Before 2022, a patient could go to an in-network hospital, get treated by an out-of-network anesthesiologist or pathologist they never met, and receive a 'surprise bill' for the difference. The No Surprises Act ended that. Federal law now caps the patient's liability at the in-network cost-share amount for most of these situations.

Federal basis

No Surprises Act

Public Law 116-260, Division BB / 45 CFR §§149.1–149.510

Read the source →

What this looks like in practice

The No Surprises Act, effective January 1, 2022, prohibits balance billing in three situations: (1) emergency services regardless of in/out-of-network status, (2) non-emergency services from out-of-network providers at an in-network facility (with limited consent-based exceptions), and (3) air-ambulance services. The patient's liability is capped at what they would have paid for in-network care. Out-of-network providers must accept the in-network rate as full payment unless the patient signed a specific NSA-compliant waiver.

When a surprise bill arrives, the dispute is straightforward: the bill is illegal under federal law if it falls within these protections. The patient can refuse to pay the excess, file a complaint with HHS, and (in many cases) have the bill resolved through the federal IDR process between provider and insurer.

How to spot it on a bill

  • 01.Bill from a provider you didn't choose (anesthesiologist, radiologist, pathologist, ER physician group) at a hospital you confirmed was in-network.
  • 02.Bill from an air ambulance you didn't book.
  • 03.A line item labeled 'out-of-network' in an otherwise in-network encounter, without an NSA-compliant pre-service written consent.

What to write — ready-to-paste language

Replace the bracketed fields with your specific details. Send by certified mail with return receipt, or via the hospital’s patient portal if it offers documented messaging. Keep a copy.

I'm writing about a balance bill from [provider] dated [date] for services at [facility]. Per the No Surprises Act (Public Law 116-260, Division BB), out-of-network providers at in-network facilities cannot balance-bill patients beyond the in-network cost-share amount unless the patient signed a specific NSA-compliant pre-service waiver. I did not sign such a waiver. I'm asking you to (1) reduce my balance to the in-network cost-share amount and (2) submit any remaining dispute to my insurer through the federal IDR process. If the bill is not corrected, I will file a complaint with the federal No Surprises Help Desk at 1-800-985-3059.

This is a starting point, not legal advice. Your specific situation may warrant additional details. Our scan tool drafts this letter automatically with your bill’s specifics filled in.

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Related scenarios

Common questions

Does the No Surprises Act apply to all insurance plans?
It applies to most private insurance plans (employer, individual market, ACA marketplace). It does NOT apply to plans that aren't subject to ERISA, like some short-term limited-duration plans, healthcare sharing ministries, or pure self-pay scenarios. Medicare and Medicaid have their own surprise-billing protections.
What's the federal IDR process?
Independent Dispute Resolution. When a provider and insurer disagree about the rate for an out-of-network service covered by the NSA, they can submit the dispute to a federally-certified arbitrator. The patient is not party to the IDR — their cost-share is fixed at the in-network amount regardless of how IDR resolves.
How do I file a complaint?
The federal No Surprises Help Desk is 1-800-985-3059, online at cms.gov/nosurprises. State insurance departments also handle surprise-billing complaints. Complaints can be filed in addition to disputing the bill directly with the provider.

P.S. The dispute language above is a starting point. Bills with this pattern often have additional issues alongside it — coding errors stacked with markup, surprise bills stacked with charity- care eligibility. The scan finds all of them in one pass. Start the audit →

P.P.S.Federal law gives you these rights regardless of how the bill arrived. Insured, uninsured, in-network, out-of-network — the underlying patient-protection statutes apply.

P.P.P.S. Bills are time-sensitive. Most insurance appeals must be filed within 180 days. Charity-care discounts at non-profit hospitals are most easily applied within 240 days of the original bill. Acting earlier costs less.