The No Surprises Act, briefly

The No Surprises Act, enacted as part of the Consolidated Appropriations Act, 2021, restricts balance billing in specified out-of-network situations and requires good faith estimates for uninsured and self-pay patients. For most outpatient MSO-PC groups it is a “know when this applies to you” statute rather than a daily operational constraint, but the good faith estimate requirement reaches any practice with self-pay patients. The Act’s implementing regulations and the independent dispute resolution process have been the subject of repeated litigation and rulemaking since 2021. Verify current requirements and IDR procedures with counsel or current agency guidance before relying on specifics.

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What it covers

Three main protections:¹

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1. Emergency services

Out-of-network emergency services are subject to balance billing protections. The patient’s cost-sharing is calculated as if the care were in-network, and the provider generally may not bill the patient for the balance. Applies regardless of the facility’s or provider’s network status.

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2. Non-emergency services by out-of-network providers at in-network facilities

The classic surprise bill: a patient goes to an in-network hospital and is treated by an out-of-network anesthesiologist, radiologist, pathologist, or assistant surgeon they never chose. Protections apply, and for certain ancillary service categories the patient cannot waive them through notice-and-consent.

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3. Good faith estimates for uninsured and self-pay patients

The provision with the broadest reach for ordinary outpatient practices. Providers must furnish a good faith estimate of expected charges to uninsured and self-pay individuals who schedule an item or service or who request an estimate. The estimate covers the primary item or service and reasonably expected related items and services.

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Where it bites an MSO-PC group

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Good faith estimates in practice

What a GFE generally must include:

• Patient name and date of birth
• A description of the primary item or service, and the scheduled date
• An itemized list of items and services reasonably expected, grouped by provider or facility
• Applicable diagnosis and service codes with expected charges
• Provider and facility names, NPIs, and TINs
• A disclaimer that the estimate is not a contract and that actual charges may differ

Timing requirements are keyed to when the service is scheduled or the estimate is requested, with shorter windows for near-term scheduling. Confirm the current timing rules. There is also a patient-provider dispute resolution process available where billed charges substantially exceed the estimate.

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The IDR process

Where the Act applies and the provider and plan disagree on the out-of-network rate, the balance is resolved between them, not with the patient, through an independent dispute resolution process, after an open negotiation period. Structurally: each side submits an offer, and the certified IDR entity selects one of them (a “baseball arbitration” format) considering specified factors. The process has been repeatedly litigated, particularly regarding the weight given to the qualifying payment amount, and administrative fees and batching rules have changed. If you operate in an affected specialty, treat IDR strategy as a specialist function and verify current procedure.

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What to do about it

If you’re a fully in-network outpatient practice:

• Implement good faith estimates for self-pay and uninsured patients
• Understand that in-network balance billing was already prohibited by your contracts
• Otherwise, monitor rather than build

If you’re out-of-network anywhere, or hospital-based:

• Map which of your service lines and facilities trigger protections
• Implement notice-and-consent where it is available, noting it is unavailable for certain ancillary categories
• Build the IDR workflow: track deadlines, prepare offers, and decide whether to handle in-house or engage a specialist
• Model the revenue impact; for some out-of-network models the Act changes the economics materially

Everyone:

• Verify state law too. Many states had surprise-billing statutes before the federal Act, and the interaction between state and federal rules depends on plan type and state law. Self-funded ERISA plans are generally governed by the federal framework; fully-insured plans may be subject to a state process. See Payers vs insurance companies.

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Sources

1. No Surprises Act, Consolidated Appropriations Act, 2021, Pub. L. 116-260, div. BB, tit. I. CMS, No Surprises Act overview and Good Faith Estimates. Implementing regulations at 45 C.F.R. pts. 149, 150 and parallel provisions. Verify current requirements — the regulations and IDR process have been repeatedly amended and litigated.