The No Surprises Act fundamentally changed the patient billing relationship for out-of-network care and uninsured patients. Two years into full implementation, many practices are still not fully compliant — either because they don't understand all the requirements or because they've treated compliance as optional. Neither is a sustainable position.
The financial stakes of NSA noncompliance run in both directions. Non-compliance can result in CMS penalties. But a well-run NSA compliance process also creates a structured framework for transparent patient billing that actually improves collection rates and reduces patient billing disputes.
Good Faith Estimates — The Core Requirement
The NSA requires providers to give uninsured and self-pay patients a Good Faith Estimate (GFE) of expected charges before scheduling or upon request. The GFE requirement applies when services are scheduled at least three business days in advance — and for services scheduled at least 10 business days out, there are additional requirement specifics.
The GFE must include: an itemized list of expected items and services, the expected charges for each, any reasonably expected co-providers and their estimated charges, a statement explaining the patient's right to dispute if actual charges significantly exceed the estimate, and the facility NPI and tax ID.
"Significantly exceed" has a specific legal definition: the actual charges are $400 or more above the GFE. When this threshold is breached, the patient has the right to initiate the patient-provider dispute resolution process — a CMS-administered process where the patient contests the charges.
GFEs for Insured Patients — The Health Plan GFE
There's a separate but related GFE requirement for insured patients: when a patient asks for cost information, their health plan is required to provide a personalized cost estimate. Providers are increasingly asked by health plans to supply charge and service information to support this process. While the provider-to-patient GFE is most relevant for uninsured patients, understanding the ecosystem helps practices prepare for plan data requests.
Independent Dispute Resolution — The IDR Process
The IDR process is available to resolve payment disputes between providers and health plans for out-of-network emergency services and certain other services covered by the NSA. The IDR arbiter selects between the provider's submitted amount and the plan's offered amount — they cannot choose a middle ground.
For providers who understand the IDR process, it's a legitimate revenue recovery tool. The IDR statistics published by CMS show that providers win a significant majority of IDR disputes — which reflects the fact that plan initial payment offers are often below market rates, and arbiters are required to consider qualified payment amounts, which are typically higher than what plans offer initially.
Balance Billing Prohibitions — What You Cannot Collect
For emergency services and certain non-emergency services from out-of-network providers at in-network facilities, the NSA prohibits balance billing the patient beyond in-network cost-sharing levels. This is a hard prohibition — violating it carries penalties and gives patients the right to dispute charges.
Understanding exactly which services are covered by the balance billing prohibition is essential because not all out-of-network services are covered. Emergency services at any facility, non-emergency services from out-of-network providers at in-network facilities where the patient didn't have a realistic choice of provider, and certain air ambulance services are covered. Scheduled out-of-network care at an out-of-network facility generally is not.
