Introduction: The Persistent Problem of Unexpected Medical Bills
Imagine finishing a hospital visit only to face a bill that you never anticipated. It happens more often than you think. Surprise medical bills and balance billing have long been issues that confuse and financially strain patients. Although the No Surprises Act became law in 2022 with the goal of eliminating these unexpected costs, many patients continue to face challenges due to enforcement gaps and system complexities.
For healthcare providers and administrators, understanding the current landscape of billing protections and how to implement best practices is crucial. This article is designed to offer practical insights, expert opinions, and detailed strategies to help healthcare professionals improve transparency and patient experience related to medical billing.
What Are Surprise Billing and Balance Billing?
Before we dive deeper, let's clarify the terminology:
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Surprise Billing: Occurs when patients receive care from out-of-network providers without knowing it—often in emergencies or during procedures at in-network facilities but involving specialists who are out-of-network.
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Balance Billing: Happens when providers bill patients for the difference between their charges and what insurance covers.
Both practices have been a source of financial distress and are at the center of recent legislative reforms.
The Background: How Surprise Billing Became a Crisis
Patients naturally assume that if they visit an in-network hospital, all providers involved are also in-network. Unfortunately, this assumption is often incorrect due to fragmented healthcare provider networks. Emergencies further complicate matters since patients cannot select providers.
Such billing surprises have prompted extensive policy discussions and legislation aimed at protecting patients.
The No Surprises Act: Key Provisions and Protections
Enacted in December 2020 and effective from January 2022, the No Surprises Act aims to eliminate many forms of surprise billing by:
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Banning balance billing for emergency services regardless of network status.
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Restricting balance billing for non-emergency services performed by out-of-network providers at in-network facilities.
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Mandating transparency, including good-faith cost estimates and clear communication about provider network status.
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Establishing an Independent Dispute Resolution (IDR) process for providers and insurers to settle payment disagreements without involving the patient.
While this federal law preempts less protective state laws, enforcement and full implementation remain ongoing challenges.
Recent Data and Trends: What the Numbers Reveal
Despite the protections, reports from 2025 indicate that patients still experience surprise billing issues.
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The Kaiser Family Foundation reports tens of thousands of complaints to the Centers for Medicare & Medicaid Services (CMS), highlighting gaps in enforcement and delays in implementing all provisions of the Act.
Source: Kaiser Family Foundation -
The American Medical Association notes a 40% decrease in provider reimbursements since the law's enactment and emphasizes that the IDR process has introduced administrative burdens.
Source: AMA Advocacy Update
Analysis: Aspirion -
The JAMA Health Forum highlights how providers are innovating with package pricing and integrating cost transparency into workflows but face challenges incorporating ancillary services into cost estimates.
Source: JAMA Health Forum
Expert Views: Insights from Thought Leaders
Dr. Emily Rivera, Healthcare Policy Analyst
"The No Surprises Act represents a fundamental change, but awareness among patients and providers remains low. Educating both groups is essential to ensure the law fulfills its promise."
Dr. Mark Stevens, Hospital Administrator
"Technology helps us identify out-of-network providers early, but it must be paired with clear communication so patients understand potential costs before care."
Laura Chen, Patient Advocacy Director
"Patients often feel overwhelmed by surprise bills. Providing clear, upfront information and advocating for stronger enforcement are critical steps toward reducing financial harm."
Practical Recommendations for Healthcare Providers
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Conduct Regular Network Verification
Frequently update and audit provider network participation data, especially for specialists and ancillary providers. -
Communicate Proactively
Inform patients about the network status of all providers involved in their care, using plain language and written notices. -
Provide Good-Faith Estimates and Obtain Consent
Whenever possible, offer detailed cost estimates before services and secure informed consent for out-of-network care. -
Utilize Technology
Integrate electronic health records with insurance data to flag potential billing issues and support patient counseling. -
Train Staff on Billing Policies
Equip billing and front-line staff to explain patients’ rights and handle billing inquiries with empathy. -
Engage in IDR Process Effectively
Develop internal expertise to navigate dispute resolution efficiently, minimizing delays and patient involvement.
Empowering Patients: What They Can Do
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Verify Provider Networks before receiving care, especially for specialists.
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Request Cost Estimates and ask questions about potential charges.
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Review Bills Carefully and challenge any unexpected or unclear charges.
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File Complaints with state insurance regulators or request independent dispute resolution.
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Stay Informed about their rights under federal and state laws.
Reflecting on Industry Practices: Moving Beyond Compliance
Many healthcare organizations treat surprise billing as a regulatory hurdle rather than a patient experience priority. Elevating transparency and financial communication to a core organizational value is necessary to truly resolve the issue.
Embedding financial counseling within the patient journey—not just billing departments—can build trust and reduce confusion.
Case Study: A Hospital’s Approach to Reducing Surprise Billing
A regional hospital network implemented:
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Automated network verification linked with scheduling software.
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Staff training focused on financial transparency.
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Standardized good-faith estimate protocols shared with patients.
Outcomes included a 40% drop in surprise billing complaints and measurable improvements in patient satisfaction.
Myth Busting: Clarifying Common Misunderstandings
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Myth: Surprise billing only happens in emergencies.
Fact: It also occurs during routine procedures involving out-of-network specialists. -
Myth: The No Surprises Act eliminates all surprise bills.
Fact: Some exceptions remain, and enforcement is ongoing. -
Myth: Patients have no options if billed unexpectedly.
Fact: They can dispute charges and use legal protections.
Frequently Asked Questions (FAQs)
Q: What types of care does the No Surprises Act cover?
A: Emergency services, non-emergency services from out-of-network providers at in-network facilities, and certain air ambulance services.
Q: How can patients dispute surprise bills?
A: They may file complaints with insurance regulators or initiate the independent dispute resolution process.
Q: Can providers balance bill for elective out-of-network services?
A: Only if the patient has been informed and consents in writing beforehand.
Q: What tools help providers comply with billing transparency?
A: Integrated EHR systems, staff training programs, and standardized patient communication materials.
Three Calls to Action
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Educate your teams and patients today about billing rights to prevent financial distress.
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Advocate for transparency and enforcement within your healthcare community.
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Lead change by sharing your insights and promoting best practices that prioritize patient trust and financial clarity.
References
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Kaiser Family Foundation. “No Surprises Act Implementation and Impact.” July 18, 2025.
https://kffhealthnews.org/news/article/no-surprises-act-bills-keep-coming-health-insurance-cms-networks-emergency-care/ -
American Medical Association. “Patient Financial Protection: Trends in Surprise Billing Complaints.” July 11, 2025.
https://www.ama-assn.org/health-care-advocacy/advocacy-update/july-11-2025-national-advocacy-update
Aspirion. “Out-of-Network Recovery Under the No Surprises Act.”
https://www.aspirion.com/out-of-network-recovery-under-the-no-surprises-act-patient-protections-and-provider-headaches/ -
JAMA Health Forum. “Healthcare Providers’ Perspectives on Billing Transparency.” 2025.
https://jamanetwork.com/journals/jama-health-forum/fullarticle/2778428
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#NoSurprisesAct #SurpriseBilling #BalanceBilling #PatientRights #HealthcareTransparency #MedicalBilling #HealthPolicy #PatientAdvocacy #HealthcareCompliance #PhysicianLeadership
About the Author
Dr. Daniel Cham is a physician and medical consultant with expertise in medical technology, healthcare management, and medical billing. He provides practical insights for professionals navigating complex healthcare challenges. Connect with Dr. Cham on LinkedIn:
linkedin.com/in/daniel-cham-md-669036285
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