How surprise bills happen
You go to an in-network hospital for surgery. The surgeon is in-network. But the anesthesiologist, the radiologist reading your imaging, or the assistant surgeon is out-of-network. You never chose these providers. You did not know they were out-of-network. After the procedure, you receive a bill for thousands of dollars from a provider you have never heard of.
This scenario was extremely common before 2022. A 2020 KFF analysis found that 1 in 5 emergency room visits and 1 in 6 in-network hospital stays involved at least one out-of-network charge.
What the No Surprises Act does
The No Surprises Act, effective January 1, 2022, prohibits out-of-network providers from billing you more than your in-network cost-sharing amount in three situations: emergency care at any facility, non-emergency care at an in-network facility when you did not receive sufficient advance notice, and air ambulance transport from non-network providers.
Under the law, the dispute about the actual payment amount is handled between the provider and the insurer through an independent dispute resolution (IDR) process. You are not involved and pay only your in-network cost-sharing amount.
The consent exception
For non-emergency services, an out-of-network provider can balance bill you if: they give you written notice at least 72 hours before the service, the notice explains that you have the right to choose an in-network provider, the notice gives you a good faith cost estimate, and you sign a consent form acknowledging all of this.
This consent exception cannot be used for certain specialists, including anesthesiologists, pathologists, radiologists, and neonatologists when they are the only provider available at an in-network facility.
Ground ambulance: still a gap
Ground ambulance services were explicitly excluded from the No Surprises Act. Congress directed an advisory committee to study the issue and report recommendations. As of May 2026, no federal ground ambulance balance billing protection is in effect. Some states have enacted their own protections.
If you receive a large surprise bill from a ground ambulance service, check your state insurance commissioner's website for state-specific protections. Also check whether your insurer has any out-of-network emergency provisions that might apply.
How to respond to a surprise bill
If you receive a bill from an out-of-network provider for a service that should be covered by the No Surprises Act, do not pay it. Contact your insurer and report the bill. Your insurer is responsible for handling the payment dispute with the provider.
File a complaint with the No Surprises Help Desk at 1-800-985-3059 or at cms.gov/nosurprises. Violations of the No Surprises Act carry civil monetary penalties of up to $10,000 per violation.
Frequently asked questions
How do I know if my bill is a surprise bill covered by the No Surprises Act?
The bill is likely covered if it is from an out-of-network provider for emergency services at any facility, or from an out-of-network provider at an in-network hospital or surgery center for a service you scheduled through that facility. Contact your insurer to confirm.
Can the No Surprises Act help with bills I already paid before 2022?
No. The law applies to services received on or after January 1, 2022. Bills for services before that date are not covered.
What if my employer plan is self-funded? Does the No Surprises Act apply?
Yes. The No Surprises Act applies to both insured and self-funded employer health plans. It also applies to non-grandfathered individual and group health insurance.
Does the No Surprises Act cap what providers can charge each other?
It caps what they can charge you. It does not set the final payment between the provider and insurer. That is determined by negotiation or the federal IDR process. Providers and insurers dispute those amounts among themselves, not with you.