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No Surprises Act for Providers: What You Can (and Cannot) Bill
By the PolicyZen Team · Updated March 2026 · 9 min read
The No Surprises Act (NSA), effective January 2022, fundamentally changed what out-of-network providers can bill patients for certain services. For most emergency care and many ancillary services at in-network facilities, patients can only be billed their in-network cost-sharing amounts — regardless of whether the treating provider is in their network. Understanding the law's scope, exceptions, and Independent Dispute Resolution (IDR) process is now a billing compliance requirement.
The core NSA rule: OON providers at in-network facilities for certain services cannot balance bill patients beyond their in-network cost-sharing amount. The provider's dispute is with the payer — not the patient. The IDR process is the mechanism for resolving payment disputes with payers when the provider believes the QPA (Qualifying Payment Amount) is insufficient.
What the NSA Covers: The Surprise Billing Prohibition
- Emergency services: OON emergency care at any facility — hospital, freestanding ED — regardless of the patient's plan. Patient pays in-network cost-sharing only. Provider bills the insurer and resolves payment through IDR if disputing the amount.
- Non-emergency services at in-network facilities: When an OON provider renders non-emergency services at a facility where the patient is already an in-network patient — typically anesthesiologists, radiologists, pathologists, hospitalists, and surgical assistants. Patient did not "choose" an OON provider — they chose an in-network facility.
- Air ambulance services: OON air ambulance is covered under NSA; patient's cost-sharing is capped at in-network rates.
The Consent Exception: When You CAN Balance Bill
For certain non-emergency services at in-network facilities, OON providers CAN balance bill — but only with proper advance notice and written patient consent obtained at least 72 hours before the scheduled service (or 3 hours before for same-day scheduling). The notice must:
- Be provided in plain language in the patient's preferred language
- Disclose the provider's OON status and an estimated cost
- Inform the patient they have the right to seek an in-network provider instead
- Include a list of in-network alternatives if available
Important: Consent cannot be obtained as a condition of receiving emergency services. It cannot be obtained from patients who don't have a meaningful alternative (e.g., the only anesthesiologist available for the procedure). CMS has challenged consent forms that bury the disclosure in general intake paperwork.
The IDR Process for Payment Disputes
When a payer pays an OON claim at the Qualifying Payment Amount (QPA — essentially the median in-network rate) and the provider believes that's insufficient, the IDR process is the remedy:
- Open negotiation period: 30 days from payment notice
- If no agreement: either party initiates IDR within 4 days
- IDR entity selects between payer's offer and provider's offer (baseball arbitration)
- Filing fee: $350 per party (2024 rates); winner's fees sometimes paid by loser
- Decision binding on both parties
The IDR process was designed for legitimate payment disputes — not as a routine billing strategy. High-volume IDR filings by provider groups have attracted regulatory scrutiny. Use IDR for cases where the QPA is genuinely below market for the complexity of care rendered — not as a systematic way to extract above-market rates from every payer for routine services.
Good Faith Estimate (GFE) requirements for uninsured and self-pay patients: The NSA also requires providers to provide a GFE of expected charges to uninsured and self-pay patients before scheduled services. GFEs must be provided at least 3 days before a scheduled service (or upon request). Charges that exceed the GFE by more than $400 can be disputed through the NSA's Patient-Provider Dispute Resolution process.
Frequently Asked Questions
What does the No Surprises Act prohibit providers from doing?
The No Surprises Act (NSA) prohibits out-of-network providers from balance billing patients for emergency services at in-network facilities, and for non-emergency services at in-network facilities when the patient didn't have a meaningful choice of out-of-network providers (such as anesthesiologists, radiologists, or assistant surgeons). Patients in these situations pay only their in-network cost-sharing.
When can a provider still balance bill a patient under the NSA?
Providers can balance bill with advance notice and written patient consent. For non-emergency services at out-of-network facilities, or when patients voluntarily choose an out-of-network provider at an in-network facility, providers must give at least 72 hours notice, provide a Good Faith Estimate, and obtain a signed consent form before delivering care.
What is the Independent Dispute Resolution (IDR) process?
The IDR process is how providers and insurers resolve payment disputes for NSA-covered services when they can't agree. Either party can initiate IDR within 30 business days after the 30-day negotiation period. An independent arbitrator selects either the provider's or the insurer's offer — the offer closest to the qualifying payment amount (QPA) typically prevails.
What is the Qualifying Payment Amount (QPA) and why does it matter?
The QPA is the median in-network contracted rate for the same service in the same geographic area, as calculated by the insurer. The QPA is used as the benchmark in IDR proceedings — arbitrators are instructed to consider it heavily when selecting between the provider's and insurer's payment offers. Knowing the QPA for your services helps providers make strategic IDR offers.
What is a Good Faith Estimate and when must providers issue one?
A Good Faith Estimate (GFE) is a written cost estimate that uninsured or self-pay patients must receive upon request or when scheduling a service. For NSA consent purposes, providers issuing the consent-to-balance-bill notice must also provide a GFE. The estimate must include the expected charges and a list of co-providers involved in the care.
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