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Rule 04, Use the No Surprises Act

The federal No Surprises Act (effective January 1, 2022) makes certain categories of "surprise" medical bills illegal. If your bill fits one of these categories, you have the strongest possible federal dispute, much stronger than a state-law overcharge claim. Use it first.

What's protected

You cannot be balance-billed (charged more than your in-network cost-sharing) in any of these situations:

  1. Emergency services at any facility, in- or out-of-network. The plan must apply your in-network deductible/copay/coinsurance and the provider cannot collect the balance.
  2. Out-of-network ancillary providers at in-network facilities. Specifically anesthesiologists, radiologists, pathologists, lab providers, assistant surgeons, hospitalists, intensivists, and neonatologists. If you went to an in-network hospital for a planned procedure and an out-of-network anesthesiologist worked on your case, the anesthesiologist cannot balance-bill you.
  3. Air ambulance services, whether in- or out-of-network.

If you are uninsured or self-pay, you are also entitled to a Good Faith Estimate at least one business day before a scheduled service. If the final bill exceeds the Good Faith Estimate by $400 or more, you can dispute it through the federal Patient-Provider Dispute Resolution (PPDR) process.

What's not protected

  • Non-emergency out-of-network care you deliberately chose (and were given proper notice and consent forms for)
  • Ground ambulance services, these were notoriously excluded from the original Act; states may have their own protections
  • Pure pricing disputes where you're being charged the in-network rate but think it's still too high (those go through the channels in [[05_negotiate_fair_price]])

How to recognize a violation

The bill probably says something like:

  • "Balance due after insurance: $X" where X is large, and the provider was out-of-network
  • "Out-of-network provider, member responsibility: $X"
  • A separate bill from a doctor with a different last name than the hospital, for a service that happened during your hospital stay

For each bill, ask:

  1. Was this an emergency? If yes → protected, regardless of network status.
  2. Was this an ancillary provider (anesthesia/radiology/pathology/lab/etc.) at an in-network facility? If yes → protected.
  3. Was this air ambulance? If yes → protected.
  4. Was I uninsured/self-pay, and did I get no Good Faith Estimate at least 1 business day before service? If yes → PPDR eligible if the final bill is ≥ $400 over what you expected.

If any answer is yes, this bill is a No Surprises Act dispute and you escalate accordingly.

What to do

  1. Do not pay the disputed portion.
  2. Send the provider templates/letter_no_surprises_violation.md, certified mail. State the specific subsection that applies (emergency, ancillary at in-network facility, etc.).
  3. Same day, file complaints:
    • Federal CMS: 1-800-985-3059 or via cms.gov/nosurprises
    • State insurance department: see references/laws_state_template.md for your state's contact info
  4. Tell your insurance company that you believe this is a balance-billing violation under the No Surprises Act, and that you expect them to process the claim at in-network rates.
  5. For Good Faith Estimate disputes: file PPDR at the federal portal (cms.gov/nosurprises) within 120 days of receiving the bill. Filing fee is currently $25 and refundable if you win.

Why this rule comes before regular disputes

A No Surprises Act violation isn't a "we should renegotiate", it's a "this bill is illegal as issued." Providers know this. The mention of a CMS complaint by name is usually enough to get the balance reversed without a fight. Don't use any softer playbook first.

What about state surprise-billing laws?

Many states had surprise-billing protections before the federal Act took effect. Where state law is broader, it usually still applies. The federal Act is a floor, not a ceiling. Tennessee, for example, has no broader pre-existing surprise-billing law for fully-insured plans, so the federal Act is the principal vehicle. Other states (e.g. California, New York, Texas) have additional protections. The state-law worksheet in references/laws_state_template.md covers how to check.

Related rules

  • [[07_appeal_insurance_denial]], if the insurer's response is to deny the claim entirely
  • [[06_small_claims]], if the provider ignores the complaint