The No Surprises Act

The No Surprises Act (Consolidated Appropriations Act, 2021, Pub. L. 116-260, div. BB, tit. I) is not one billing rule. It is a bundle of distinct obligations. It bans balance billing for out-of-network emergency care and for out-of-network care at in-network facilities, with a parallel regime for air ambulances. It requires good faith estimates for uninsured and self-pay patients. It places disclosure, continuity-of-care, and directory duties on providers. And it creates two unrelated dispute systems: one between providers and plans over the out-of-network rate, and one between patients and providers over estimates. Which parts reach you depends on three things: whether you are ever out of network, whether you work in a facility, and whether you have self-pay patients. Nearly every practice is touched by at least one. The Act’s regulations have been amended and litigated continuously since 2021. Two developments in summer 2026 are recent enough that agency guidance was still catching up when this page was written: a final rule overhauling the federal dispute process, effective August 3, and an en banc Fifth Circuit decision on August 11 vacating parts of the payer rate methodology.

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The map

The statute added parallel provisions to the Public Health Service Act: the 2799A series binds plans, the 2799B series binds providers and facilities. Providers should know the B series.¹ Implementing regulations are at 45 C.F.R. Part 149. Subpart E (§§ 149.410–.450) covers provider balance billing and disclosure. Subpart F (§ 149.510) is the federal independent dispute resolution process. Subpart G (§§ 149.610–.620) covers the good faith estimate and the patient–provider dispute process.² Which patients. The Act protects people in group health plans (including self-funded ERISA plans and non-federal governmental plans), individual-market coverage, and the Federal Employees Health Benefits program. It does not apply to Medicare, Medicaid, TRICARE, the VA, or Indian Health Service patients, because those programs already prohibit balance billing. Nor does it apply to excepted benefits or short-term plans.³

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Part 1: emergency services

A patient who receives emergency services from an out-of-network provider or facility owes only what they would have owed in network. The provider may not bill the difference (§ 149.410). “Emergency services” reach post-stabilization care until the patient can travel and has consented in writing to out-of-network treatment. This applies regardless of whether the patient chose the facility, and it cannot be waived.

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Part 2: non-emergency care at an in-network facility

The classic surprise bill: an in-network hospital, an out-of-network anesthesiologist. Section 149.420 bars balance billing for non-emergency items and services furnished by a nonparticipating provider “with respect to a visit at a participating health care facility.” Facility here means a hospital, hospital outpatient department, critical access hospital, or ambulatory surgical center; “visit” includes telemedicine, imaging, and laboratory services connected to it.⁴ Notice and consent can lift the protection for some services. The provider must give written notice at least 72 hours before the service (or, if scheduled within 72 hours, at least three hours before), a good faith estimate of the charges, and a list of participating alternatives. The patient must sign a consent, which the provider keeps for seven years. But § 149.420(b) forbids notice and consent for ancillary services:

• items and services “related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether provided by a physician or non-physician practitioner”;
• items and services “provided by assistant surgeons, hospitalists, and intensivists”;
• “diagnostic services, including radiology and laboratory services”; and
• any item or service where “there is no participating provider who can furnish such item or service at such facility”

Also excluded is anything arising from “unforeseen, urgent medical needs” during the visit.⁴ If your group is one of those specialties and out of network anywhere, the protection is absolute. The only question is what the plan pays you, which is Part 6.

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Part 3: air ambulance

Out-of-network air ambulance providers may bill only in-network cost-sharing (§ 149.440) and are subject to separate reporting requirements. Ground ambulance is not covered by the federal Act. Roughly two dozen states have their own ground-ambulance protections, and a federal advisory committee’s 2024 recommendations have not been enacted.

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Part 4: good faith estimates for uninsured and self-pay patients

This is the provision with the widest reach. It applies to every provider and facility, in every specialty and every setting, whether or not it ever bills a payer. Under § 149.610, when an uninsured or self-pay patient schedules an item or service, or asks, the “convening provider” must furnish a written good faith estimate of expected charges:⁵ “Self-pay” includes an insured patient who chooses not to submit a claim. The estimate must list the primary item or service and the items and services reasonably expected with it, with codes, expected charges, and the provider and facility names, NPIs, and TINs. It must also carry a disclaimer: that it is an estimate, not a contract, and that the patient may dispute a bill that substantially exceeds it. Co-providers. The regulation requires the convening provider to gather estimates from co-providers and co-facilities. HHS has exercised enforcement discretion on that requirement since 2022. In FAQ Part 4 (December 27, 2022) it extended that discretion “pending future rulemaking” with no end date, and the requirement remained unenforced in August 2026.⁶ You are still responsible for your own portion. Insured patients. The statute also requires estimates to be sent to the patient’s plan so the plan can produce an advanced explanation of benefits. Four years on, this remains unimplemented. HHS has said it will not enforce until rulemaking is complete, and no proposed rule had been published as of August 2026.⁶ Build the estimate into scheduling, not billing. It is triggered by scheduling or a request. Practices that treat it as a billing task generate it late or not at all.

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Part 5: the disclosure notice

Section 149.430 requires providers and facilities to disclose the balance-billing protections (federal, and any state limits) with the contact details of the enforcement agencies. Three channels: a prominent sign at the location; a link on the website homepage; and a one-page notice given to the patient no later than the request for payment or the claim submission. CMS publishes a model notice (OMB 0938-1401, valid through 2028); using it counts as “good faith compliance.” A facility and its providers may allocate the duty by written agreement: check whether your hospital contracts do.⁷ This is the requirement most commonly cited in CMS complaint data against providers. It applies to every provider that furnishes services to plan enrollees, in or out of network.

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Part 6: the federal independent dispute resolution process

Where the Act applies and no state law sets the rate, the plan makes an initial payment or denial within 30 days. If the provider disagrees, the dispute is between provider and plan, never the patient. The sequence under § 149.510 runs as follows. The parties have a 30-business-day open negotiation period. If that fails, either party initiates federal IDR within 4 business days. The parties pick a certified IDR entity, or the Departments assign one. Each side submits an offer, and the entity picks one (“baseball arbitration”), weighing the qualifying payment amount (QPA, the plan’s median contracted rate) and the other statutory factors. The losing party pays the entity’s fee. The same item cannot be re-disputed with that party for 90 calendar days.⁸ The process has been rewritten several times by the courts and once, comprehensively, by regulation:

• Texas Medical Association litigation (TMA I–IV, E.D. Tex. 2022–2023). Struck the rebuttable presumption in favour of the QPA, then the 2022 rule’s QPA-first weighting (affirmed by the Fifth Circuit, August 2, 2024), then the $350 administrative fee and the batching rule. The Fifth Circuit sitting en banc decided the QPA-methodology case on August 11, 2026. Plans may not include “ghost rates” (contracted rates for services a provider never actually furnishes) in the QPA, and may not exclude risk-sharing, bonus, and incentive payments. The exclusion of single-case agreements was upheld. The unlawful provisions were vacated rather than remanded.⁹ The Departments’ FAQ Part 73 (April 1, 2026) had already allowed plans to keep using 2021-methodology QPAs for services before October 1, 2026; expect further guidance on recalculation.
• Federal IDR Operations final rule, 91 Fed. Reg. 33900 (June 4, 2026), effective August 3, 2026. Cuts the administrative fee from $115 to $15 per party for disputes initiated on or after June 11, 2026. Moves open-negotiation notices onto the federal portal with a 15-business-day response. Requires the IDR entity to decide eligibility within 5 business days. Caps batches at 50 line items and lets anesthesiology, radiology, pathology, and laboratory batch by CPT category. Requires plans to use specified NSA claim adjustment codes on remittances for services from January 1, 2027. Creates a payer registry. Portal-dependent provisions phase in over 24 months.¹⁰ Certified IDR entity fee ranges for 2026 were unchanged at $200–$840 for single determinations and $268–$1,173 for batched.

The data favour providers who use it. In the second half of 2025, 1.37 million disputes were initiated, up 16% on the first half. Emergency medicine was 52% of determinations and radiology 15%. Providers prevailed in about 85% of determinations, and the prevailing offer exceeded the QPA in about 87%. Three revenue-cycle firms and physician staffing groups initiated roughly 38% of all disputes.¹¹ Payers challenged the eligibility of 42% of disputes, which is why the 2026 rule’s eligibility deadline matters. Collection of awards is the persistent gap. A bill to penalize late payment of IDR awards (H.R. 4710 / S. 2420, No Surprises Act Enforcement Act) was introduced in July 2025 and had not moved out of committee a year later.

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Part 7: patient–provider dispute resolution

A different process, for a different party. An uninsured or self-pay patient whose bill exceeds the good faith estimate by $400 or more may, within 120 calendar days of the bill, ask a selected dispute resolution entity to decide what is owed (§ 149.620). The patient pays a $25 administrative fee. If the provider loses, it credits the fee to the patient; if the parties settle, half. The entity decides whether the difference reflects unforeseen and medically necessary services. While the dispute is open you may not send the bill to collections or charge late fees.¹²

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Where it bites an MSO-PC group

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Enforcement and the states

States enforce first. Where a state told CMS it lacks authority or will not enforce a provision, CMS enforces directly under 45 C.F.R. Part 150. Where the state and CMS share the work, a collaborative enforcement agreement governs. The result is a patchwork. In Texas, for example, the state enforces the balance-billing bans against providers, the Texas Medical Board enforces the estimate and disclosure provisions against physicians, and CMS enforces them against every other provider type and enforces the air-ambulance provision itself. Each state’s position is set out in a CMS enforcement letter.¹³ From January 2022 through December 2025 CMS received about 40,000 complaints and closed about 15,000, producing roughly $30 million in “direct monetary relief” through corrective action. No civil money penalty against a provider had been publicly reported as of August 2026.¹⁴ The practical enforcement is a corrective-action letter and a refund with interest: cheap if you catch it, expensive if it reveals a pattern. State surprise-billing laws remain in force. Where a state has a “specified State law” that sets the out-of-network amount, it governs fully-insured plans and the federal IDR does not apply. Self-funded ERISA plans are federal unless the plan has opted into the state process. A group’s payer mix therefore determines which process it is in, plan by plan. See Payers vs insurance companies.

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Sources

1. Consolidated Appropriations Act, 2021, Pub. L. 116-260, div. BB, tit. I (Dec. 27, 2020), codified at 42 U.S.C. §§ 300gg-111 to -119 (plans) and §§ 300gg-131 to -139 (providers). Penalty and waiver: 42 U.S.C. § 300gg-134.
2. 45 C.F.R. Part 149; definitions at § 149.30; applicability at § 149.20.
3. CMS, Provider requirements and resources; 45 C.F.R. § 149.20; 5 U.S.C. § 8902(p) (FEHB).
4. 45 C.F.R. § 149.420 (quoted list at (b)); § 149.30 (“health care facility,” “visit”); 42 U.S.C. § 300gg-132.
5. 45 C.F.R. § 149.610.
6. CMS, FAQs About Good Faith Estimates for Uninsured (or Self-Pay) Individuals: Part 4 (Dec. 27, 2022); CMS, No Surprises Act implementation status. Checked August 2026: no subsequent FAQ or proposed AEOB rule located.
7. 45 C.F.R. § 149.430; CMS, Model Disclosure Notice.
8. 45 C.F.R. § 149.510; 42 U.S.C. § 300gg-111(c).
9. Texas Medical Association v. HHS, Nos. 23-40605 et al. (5th Cir. Aug. 11, 2026) (en banc, per curiam), opinion, vacating the panel decision at 120 F.4th 494 (5th Cir. 2024); Texas Medical Association v. HHS, No. 23-40217 (5th Cir. Aug. 2, 2024) (affirming TMA II). Departments’ FAQs Part 73 (Apr. 1, 2026).
10. Federal Independent Dispute Resolution Operations, 91 Fed. Reg. 33900 (June 4, 2026) (CMS-9897-F); CMS, Federal IDR operations implementation timeline (Aug. 7, 2026).
11. CMS, Federal IDR reports and public use files, including the July–December 2025 supplemental background (released July 22, 2026).
12. 45 C.F.R. § 149.620; CMS, Dispute a medical bill ($25 fee).
13. CMS, Questions and Answers on the No Surprises Act and State Laws (rev. Aug. 2023); state enforcement letters at CMS, Consolidated Appropriations Act, 2021: oversight (Texas letter, Dec. 22, 2021).
14. CMS, Complaint Data and Enforcement Report (data through Dec. 2025).