The No Surprises Act, explained for providers

What the law does

The No Surprises Act took effect January 1, 2022. It bans balance billing patients in situations where they had no meaningful choice of provider, and it replaces that lost revenue with a payment-dispute mechanism against the health plan instead of the patient.

Which services are covered

• Emergency services, including post-stabilization care until the patient can safely be moved, regardless of the facility's network status.
• Non-emergency services by out-of-network providers at in-network facilities — the classic case of an out-of-network anesthesiologist, radiologist, pathologist, assistant surgeon, hospitalist, intensivist or neonatologist at an in-network hospital or ambulatory surgical center.
• Air ambulance services by out-of-network providers. Ground ambulance is not covered federally.

What providers cannot do

• Balance bill the patient beyond in-network cost sharing for covered services.
• Ask patients to waive protections for ancillary services — emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists and intensivists cannot use notice and consent at all.
• Use notice-and-consent forms outside the narrow circumstances and timelines the rules permit. A defective waiver doesn't just fail — it can make an otherwise disputable claim ineligible.

What providers get in exchange: IDR

When a plan underpays a covered out-of-network claim, the remedy is independent dispute resolution — final-offer arbitration where the plan's qualifying payment amount is a factor but not a cap. Providers have won roughly 88% of federal determinations, and awards routinely exceed comparable in-network rates by multiples. More than 5.1 million disputes had been filed through January 31, 2026.

Good faith estimates

For uninsured and self-pay patients, the Act also requires a written good faith estimate of expected charges, with a patient-provider dispute resolution process available when the final bill exceeds the estimate by $400 or more.

Where state law fits

Twenty-two states have their own surprise-billing laws. In nearly all of them the state law covers only state-regulated plans, so self-funded ERISA coverage still runs federal. See IDR by state.

What's new in 2026

The May 2026 final rule cut IDR administrative fees to $15 per party, loosened batching, imposed eligibility-review deadlines on arbitrators, required standardized claim codes from payers, and launched a phased IDR Gateway.