How balance billing works
In-network providers have contracts with your insurer. Those contracts set a negotiated rate and require the provider to accept it as payment in full. Out-of-network providers have no such contract. They can charge any amount and then bill you for whatever your insurer does not cover.
Before the No Surprises Act, balance billing was common in emergency situations where patients had no choice of provider. Patients would go to an in-network hospital but be treated by an out-of-network physician, such as an anesthesiologist or radiologist, without their knowledge.
What the No Surprises Act prohibits
Effective January 1, 2022, the No Surprises Act (part of the Consolidated Appropriations Act, 2021) bans balance billing in three main scenarios. First, for emergency services at any hospital or free-standing emergency department, regardless of whether the facility is in-network. Second, for non-emergency services at in-network facilities when you did not receive adequate notice that a provider was out-of-network. Third, for air ambulance services from providers that are not in your insurer's network.
Under these protections, providers can only charge you your in-network cost-sharing amount, meaning your deductible, copay, or coinsurance as calculated against your in-network benefit.
When balance billing is still allowed
The No Surprises Act does not cover all situations. Out-of-network providers for non-emergency services can still balance bill you if they give you advance written notice and you sign a consent form at least 72 hours before the service. You must also be given a good faith cost estimate at that time.
Ground ambulance services are not covered by the No Surprises Act. Congress directed an advisory committee to study ground ambulance billing, but federal protections have not yet been enacted as of 2026. Some states have their own ground ambulance balance billing protections.
What to do if you receive a balance bill
First, determine if the service falls under No Surprises Act protections. If it does, the provider cannot legally collect the balance from you. Contact your insurer and report the balance bill. Insurers are required to handle disputes with out-of-network providers through an independent dispute resolution (IDR) process.
File a complaint with the No Surprises Help Desk at 1-800-985-3059 or at cms.gov/nosurprises. CMS has authority to investigate violations and assess civil money penalties of up to $10,000 per violation.
State balance billing protections
Many states had balance billing protections before the federal law. States like California, New York, Texas, and Illinois have comprehensive laws that may provide additional protections beyond the No Surprises Act. Some states cover ground ambulances and other services not included in the federal law.
Check your state insurance commissioner's website for state-specific protections. When state law is more protective than federal law, the state law applies.
Frequently asked questions
Is balance billing the same as a surprise bill?
Yes, the terms are often used interchangeably. A surprise bill is a balance bill you did not expect, typically from an out-of-network provider at an in-network facility. The No Surprises Act targets exactly this scenario.
Can I be balance billed by an air ambulance?
No. The No Surprises Act explicitly covers air ambulance services from non-network providers. You can only be charged your in-network cost-sharing amount for air ambulance transport, and you have the right to dispute bills that exceed that.
What is the independent dispute resolution (IDR) process?
When providers and insurers cannot agree on an out-of-network payment amount, they can submit to a federal IDR process administered by certified arbitrators. The patient is not involved in this process and pays only the in-network cost-sharing amount regardless of the IDR outcome.
Does the No Surprises Act apply to self-pay patients?
Partially. Self-pay patients are protected by the good faith cost estimate requirements: providers must give written estimates for scheduled services at least one business day in advance. Patients can dispute bills that exceed the estimate by more than $400 through the patient-provider dispute resolution process.