In 2022, one of the most significant consumer health protections in decades went into full effect: the No Surprises Act. It was designed to end the practice of "balance billing" — where out-of-network providers send patients bills for amounts far exceeding their expected cost-sharing.
The law has had real impact. But it's also poorly understood by patients, and some providers continue to bill in ways that may conflict with its requirements. Here's what you actually need to know.
What Is Balance Billing?
Balance billing happens when an out-of-network provider charges you the difference between their full fee and what your insurance paid. For example: your insurance pays $400 toward an anaesthesiologist's $2,000 bill. The anaesthesiologist then bills you the remaining $1,600 — even though you had no say in choosing them.
This was extremely common for services like emergency care, anaesthesiology, radiology, and pathology — services where you often don't get to pick your provider. The No Surprises Act was designed to stop it.
What the NSA Covers
The No Surprises Act protects you from surprise bills in three main scenarios:
- Emergency services at any facility, in-network or out-of-network. You pay only your in-network cost-sharing amount, regardless of whether the facility or any emergency provider is in your network.
- Non-emergency services at in-network facilities from out-of-network providers, when you didn't have advance notice or a meaningful choice. A classic example: you schedule surgery at an in-network hospital, but the assistant surgeon is out-of-network.
- Air ambulance services from out-of-network providers (covered under a separate part of the law).
What the NSA Does NOT Cover
| Situation | Covered? |
|---|---|
| Emergency care at an out-of-network ER | ✓ Yes |
| Surprise out-of-network charge at in-network facility | ✓ Yes |
| Planned out-of-network care (you knew the provider was OON) | ✗ No |
| Ground ambulance services | ✗ Not yet |
| Dental, vision, or behavioural health (separate plans) | Varies by plan |
The law also requires providers to give you a Good Faith Estimate (GFE) before scheduled services if you're uninsured or self-pay. If your actual bill exceeds the GFE by more than $400, you can initiate a Patient-Provider Dispute Resolution process.
The Consent Exception — How Providers Get Around the Law
The NSA includes a "consent and waiver" provision that allows patients to voluntarily waive their protections for non-emergency care at in-network facilities. In theory, this is for situations where a patient specifically requests an out-of-network provider.
In practice, some providers have used this as a workaround — asking patients to sign consent forms in busy pre-admission paperwork without making clear that they're waiving their NSA protections. If you signed a consent form that included waiver language but weren't explicitly told you were giving up your right to in-network cost-sharing, that waiver may not be valid.
Key rule: For the waiver to be valid, it must be a standalone document (not buried in general intake paperwork), given to you at least 72 hours before the scheduled service, and must list the specific out-of-network providers involved and their estimated charges. If these conditions weren't met, the waiver may not hold.
How to Dispute a Bill That Violates the NSA
If you receive a bill you believe conflicts with the No Surprises Act, you have several options:
- File a complaint with CMS at cms.gov/surprise-billing/patients — the agency that enforces the NSA
- Contact your insurer — for employer-sponsored plans, the insurer handles the dispute with the provider directly
- Submit a formal written dispute to the provider citing the specific NSA provision that applies
Written disputes citing the NSA specifically — by name and section — tend to be taken significantly more seriously than verbal complaints or generic billing disputes. ClawBack can generate this letter for you in minutes. Try it free →