Navigating the No Surprises Act: How to Manage Out‑of‑Network Billing and Patient Estimates
The healthcare landscape has long struggled with surprise medical bills—unexpected charges that patients receive after unknowingly receiving care from out-of-network providers. To address this problem, the U.S. government enacted the No Surprises Act (NSA), which took effect on January 1, 2022. Now in 2025, enforcement is stricter, penalties are steeper, and compliance expectations have risen.
For medical practices, especially those offering hospital-based, emergency, or specialty care, navigating the No Surprises Act requires operational changes, billing safeguards, and proactive communication. In this blog, we’ll explore what the law means today, how to manage out-of-network billing risks, and how to provide compliant, good-faith estimates to patients.
What Is the No Surprises Act?
The No Surprises Act (NSA) is a federal law that protects patients from unexpected medical bills in certain situations, particularly when they receive:
- Emergency care from out-of-network providers
- Non-emergency care from out-of-network providers at in-network facilities
- Air ambulance services
It prevents out-of-network providers from balance billing patients—charging them the difference between what the provider charges and what insurance pays—for these services.
Who Does the NSA Affect?
- Healthcare providers (physicians, facilities, labs, imaging centers)
- Health plans and insurers
- Medical billing companies
- Patients receiving out-of-network care unknowingly
Specialties most impacted include anesthesiology, emergency medicine, radiology, and surgery, where out-of-network billing was common in hospital settings.
Key Provisions Practices Must Know
- Balance Billing Protections
Providers may not bill patients for more than their in-network cost-sharing amount in applicable situations, even if the provider is out-of-network.
- Good Faith Estimates (GFE)
Providers must give uninsured or self-pay patients a written estimate of expected charges before care is delivered.
- Independent Dispute Resolution (IDR)
When providers and payers disagree on out-of-network payments, they can use an arbitration process called IDR to settle disputes.
- Notice and Consent Exceptions
In limited, non-emergency cases, out-of-network providers can obtain written patient consent to waive protections—but it must follow a strict format and timeline.
Impact on Out-of-Network Billing
The No Surprises Act significantly limits a provider’s ability to collect above the in-network rate unless proper consent and notice procedures are followed. This makes it critical to:
- Know when NSA protections apply
- Ensure compliance with notice and consent rules
- Avoid sending balance bills in prohibited scenarios
Steps to Manage Out-of-Network Billing Under the NSA
✅ 1. Verify the NSA Applicability
Before billing, determine if the service falls under NSA protection:
| Situation | Does NSA Apply? |
| Emergency care by out-of-network provider | ✔ Yes |
| Non-emergency care at in-network hospital (by OON provider) | ✔ Yes |
| Elective surgery with signed notice and consent | ✖ No (if valid consent obtained) |
| Fully out-of-network care with self-pay patient | ✖ No (GFE applies instead) |
✅ 2. Automate Eligibility and Provider Status Checks
Use real-time eligibility tools to verify:
- Whether the patient’s plan is covered under NSA
- The provider’s in-network or out-of-network status
This helps your staff flag NSA-protected cases early and avoid surprise billing violations.
✅ 3. Implement a Strong Good Faith Estimate (GFE) Workflow
For self-pay or uninsured patients, provide a written GFE that includes:
- Anticipated services and charges
- Facility fees, lab tests, imaging, anesthesia (if known)
- Timing of service delivery
- A disclaimer about possible additional items
Timeline: Must be provided within 3 business days of scheduling, or upon request.
Tip: Use your EHR or RCM platform to auto-generate GFE templates and log delivery.
✅ 4. Use the Standard Notice and Consent Form When Allowed
In non-emergency settings, some out-of-network providers may still bill beyond the in-network rate if the patient signs a government-approved notice and consent form.
Key requirements:
- Provide at least 72 hours before service (or same-day for same-day services)
- Clearly state that care is out-of-network
- Include cost estimate and network alternatives
- Use CMS-approved templates only
Be aware that some services (e.g., emergency care, anesthesia at hospitals) may not be eligible for this opt-out, even with consent.
✅ 5. Monitor the IDR Process if Disputes Arise
If your out-of-network claim is underpaid, you can enter the Independent Dispute Resolution (IDR) process within 30 days of the payer’s payment or denial.
- Both parties submit their best offer
- A third-party arbitrator picks one
- The losing party pays the arbitration fee
Tip: Maintain strong documentation, medical necessity evidence, and comparable payment data to justify your rates.
✅ 6. Train Your Staff Thoroughly
Your front desk, billing, coding, and scheduling teams should understand:
- Which services are subject to NSA rules
- How to explain patient protections clearly
- When to issue GFEs or collect signed consents
- What to do when patients dispute their bills
Ongoing education ensures consistent compliance and prevents costly mistakes.
Penalties for Non-Compliance
Violating the NSA can result in:
- Civil monetary penalties up to $10,000 per violation
- Increased payer scrutiny or network exclusion
- Patient complaints and legal exposure
- Brand reputation damage
In 2025, enforcement audits by HHS are increasing, with a focus on emergency and hospital-based providers.
Technology Tools That Help
Consider using:
- Eligibility verification software with payer plan detection
- Automated GFE generators linked to scheduling systems
- Contract management tools to identify in-network status
- Compliance dashboards for tracking NSA-related workflows
These tools help avoid manual errors and strengthen audit readiness.
Conclusion
The No Surprises Act has transformed out-of-network billing, requiring providers to rethink how they communicate with patients, verify benefits, and submit claims. While it may limit certain billing practices, it also provides a framework for greater transparency, patient trust, and operational clarity.
With the right systems and staff training, your practice can comply confidently, minimize risk, and still maintain strong revenue performance.
✅ Need Help with NSA Compliance?
At Right Medical Billing, we help practices build NSA-compliant workflows—everything from eligibility checks and good faith estimates to payer negotiations and IDR submissions. Let us help you streamline your billing while staying within the law.
