Received a surprise medical bill? Federal law may mean you do not owe it
If you received a medical bill that seems larger than expected — particularly a bill from a provider you did not choose, like an anesthesiologist, radiologist, or emergency room physician — there is a good chance you do not legally owe it. Federal law has banned this practice, known as balance billing or surprise billing, in most situations since January 1, 2022.
This page explains what balance billing is. This includes information on exactly which bills you are protected from under the No Surprises Act, what gaps still exist, what to do when you receive a bill you believe you should not owe, and where to file a complaint if a provider tries to collect anyway.
What balance billing is and why it happens
Balance billing happens when an out-of-network provider charges you the difference between their full rate and what your insurance agreed to pay. Your insurance pays its portion, and the provider sends you a bill for the rest — the "balance."
This most commonly happens in situations where you had little or no control over who treated you. You go to an in-network hospital for surgery, and the anesthesiologist who works there happens to be out of network. You have a car accident and the nearest emergency room is out of network. You did not choose these providers — in many cases you did not even know they were out of network until the bill arrived weeks later. That is why it is called a surprise bill.
Before 2022, this was largely legal and patients were often left paying thousands of dollars they had no way to anticipate. The No Surprises Act changed that.
What the No Surprises Act protects you from
The No Surprises Act took effect January 1, 2022. It bans balance billing in three specific situations for people with health insurance through an employer, a marketplace plan, or a plan purchased directly from an insurer.
- Emergency care — if you receive emergency services, you can only be charged your plan's normal in-network cost-sharing: your copay, coinsurance, or deductible. It does not matter whether the emergency room, the physicians treating you, or both are out of network. The provider cannot bill you for anything beyond what you would owe at an in-network facility. This protection applies even if you did not know the facility was out of network when you arrived.
- Out-of-network providers at in-network facilities — if you receive non-emergency care at an in-network hospital or ambulatory surgical center, certain out-of-network providers at that facility cannot balance bill you. This covers anesthesiologists, radiologists, pathologists, neonatologists, assistant surgeons, hospitalists, and intensivists. These are exactly the specialists patients routinely encounter without being able to choose them. Unless you gave written, informed consent at least 72 hours in advance agreeing to waive your protections — which providers are not supposed to pressure you into — they cannot charge you more than your in-network cost-sharing.
- Air ambulance services — out-of-network air ambulance providers are covered. If you were transported by helicopter or fixed-wing aircraft, you cannot be balance billed beyond your normal in-network cost-sharing.
In all three situations, the dispute over how much the provider gets paid is between the provider and your insurer — not between the provider and you. The law established an independent dispute resolution process for providers and insurers to resolve payment disagreements. You are not part of that process and you do not owe any additional amount while it is happening.
What is not covered — the ground ambulance gap
Ground ambulance services are the most significant gap in the No Surprises Act. If you were transported by a regular ambulance and received a large bill, federal law does not currently protect you from balance billing for that service. Some states have enacted their own protections for ground ambulance — check with your state insurance commissioner to find out what applies in your state. For help managing ambulance bills regardless of whether they qualify as balance billing, see [ambulance bill payment assistance.
Medicare, Medicaid, TRICARE, VA, and Indian Health Service plans are not covered by the No Surprises Act because those programs already have their own billing protections in place.
If you do not have insurance — the good faith estimate right
If you are uninsured or choosing to pay out of pocket, providers are required to give you a good faith estimate of expected costs before scheduled non-emergency services. If your final bill is $400 or more above that estimate, you can dispute the charges through a federal patient-provider dispute resolution process. Contact the provider first to resolve the discrepancy, and if that fails, submit a dispute through https://www.cms.gov/nosurprises.
What to do when you receive a bill you believe you should not owe
Do not pay it and do not ignore it. Paying a bill you do not legally owe is not required and sets a poor precedent. Ignoring it entirely risks the bill going to collections.
First, contact your insurer. Explain that you received a bill you believe is prohibited under the No Surprises Act and ask your insurer to confirm whether the service is covered under the law's protections. Get a reference number for the call.
Second, contact the provider's billing department. Tell them you are disputing the bill as a potential No Surprises Act violation and that you are only responsible for your in-network cost-sharing. Put this in writing. Ask them to put any collections activity on hold while the dispute is resolved.
Third, if the provider or your insurer is unresponsive, file a complaint with the federal No Surprises Help Desk at 1-800-985-3059, available 8 a.m. to 8 p.m. Eastern time seven days a week. You can also submit a complaint online at https://www.cms.gov/nosurprises. CMS investigates complaints and can take enforcement action against providers who violate the law.
If the bill has already been sent to a collections agency, tell the agency in writing that you are disputing the debt as a potential No Surprises Act violation. A written dispute stops collection activity while the dispute is being resolved. More on your rights when dealing with collections agencies is at debt collection laws for medical bills.
A medical billing advocate can also handle this dispute on your behalf. Many work on contingency and charge only if they save you money. More on the medical billing advocates guide.
What your insurer is required to do
When a No Surprises Act situation applies, your insurer must apply the Qualifying Payment Amount as the basis for your cost-sharing. This is essentially a median in-network rate for the same service in your geographic area — it is how your cost-sharing is calculated when the actual provider is out of network. Your out-of-pocket responsibility is based on that rate, not on the provider's full charge.
Insurers are also required to keep their provider directories current so patients can accurately identify in-network providers before receiving care. If you used a provider listed as in-network in your insurer's directory but the insurer later claims they were out of network, you have additional protections — contact your state insurance department.
State laws may give you additional protections
The No Surprises Act sets a federal minimum. Many states have their own surprise billing laws that go further — covering more situations, applying to more types of insurance, or providing stronger remedies. Your state insurance department is the right place to find out what additional protections apply in your state.
If you believe a provider has violated state law, file a complaint with your state insurance department or your state attorney general's consumer protection office in addition to the federal complaint.
This page provides general educational information about federal and state protections against surprise billing and balance billing. Individual situations vary. This is not legal advice. For guidance specific to your situation, contact your insurer, the CMS No Surprises Help Desk, a medical billing advocate, or a free legal aid attorney.
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