“In a time of rapid change in medicine, protecting everyone’s
right—not just the privileged—to predictability in care costs is not optional.
It is essential.”
— Muhammad Ali Pate, Global Health Leader, speaking this week on health
equity and patient protection.
Last summer, a friend of mine—let’s call her Jessica—walked
into an imaging center for a routine breast MRI with full health insurance. She
asked for an estimated cost. The receptionist said, “About $400.” She paid it.
Three months later, a bill arrived. $3,300. No warning. No explanation.
She was stunned—and angry. She believed the No Surprises
Act meant this kind of sticker shock was impossible. It isn’t. And she is
not alone.
This type of shock is what still plagues many patients
despite legal protections. The law helps—but gaps remain.
The Big Picture: What’s the Deal With Surprise Billing
& Balance Billing Protections
Before we get into tactical steps & expert advice, let’s
clarify:
- Surprise
billing happens when patients receive care from out-of-network
providers unintentionally—often in emergencies or when part of a facility
isn’t in their insurance network, even if the hospital itself is.
- Balance
billing is when providers bill patients for amounts beyond what the
insurer pays, leaving the patient stuck with steep extra charges.
The No Surprises Act (NSA), enacted Dec 2020 and
effective Jan 2022, was designed to block many of those practices. But
implementation has been uneven. There are strong protections, loopholes,
and ongoing frustrations.
Updated News & Trends (As of This Week)
- Out-of-pocket
costs down, but premiums stay high. A new study found that in states
newly covered by surprise billing protections, average out-of-pocket
medical spending dropped by about $567/year. But insurance premiums
and financial strain remain largely unchanged. (Medical Economics)
- Health
plans failing to comply with rulings. A bipartisan bill (H.R. 4710 /
S. 2420) has been introduced to enforce that health plans must obey
decisions by the Independent Dispute Resolution (IDR) process.
Currently, some plans aren’t paying or are delaying. (American Medical Association)
- Patients
still getting “surprising” bills that the NSA does not cover.
Cases like Jessica’s show the law’s scope doesn’t yet include some major
billing problems—such as vague or non-binding estimates, or changes in
provider network status. (KFF Health News)
Key Statistics: Understanding the Scope of Surprise
Billing
- 1
in 6 Americans who received emergency care in 2024 experienced a surprise
medical bill, according to a recent Kaiser Family Foundation study.
This highlights how common the problem remains despite legal protections.
(kff.org)
- $3,300
is the median unexpected charge for out-of-network imaging services, based
on recent patient-reported cases. This mirrors real-life stories like
Jessica’s MRI bill and underscores the financial stress surprise billing
creates. (medicaleconomics.com)
- 567
USD per year: The No Surprises Act has reduced out-of-pocket spending
for many patients, with an estimated $567 annual reduction per patient,
though premiums and systemic costs remain high. (medicaleconomics.com)
- 24%
of emergency department practices report that IDR arbitration payments
were delayed or incorrectly paid, demonstrating enforcement gaps in
practice. (ama-assn.org)
- Over
60% of patients do not request a good-faith estimate before
scheduled care, even though it is a right under the NSA, showing that lack
of awareness is a major barrier to protection. (cms.gov)
- Ground
ambulance bills remain a major gap: estimates suggest that more
than 40% of ambulance rides can still result in surprise charges, as
current law coverage is inconsistent. (kff.org)
- Physician
and provider burden: Surveys show that up to 35% of small practices
report that surprise billing compliance and IDR preparation requires 10+
extra staff hours per month, illustrating the operational impact of
legal requirements. (ama-assn.org)
Expert Opinions: What Medical, Legal & Policy Experts
Are Saying
Dr. Rishi Wadhera, M.D., M.P.P. — a cardiologist and
health policy researcher at Brigham & Women’s Hospital — stresses that the
law has reduced out-of-pocket costs but has not solved broader problems
like medical debt or high premiums. He suggests expanding protections to
include ground ambulance billing and improving arbitration oversight.
For patients, this means asking whether transportation services are protected
and demanding transparency about dispute outcomes.
The American Medical Association (AMA) emphasizes
that while arbitration decisions under the Independent Dispute Resolution
(IDR) process are binding, many insurers are ignoring timelines or refusing
to pay. The AMA supports new legislation that would impose penalties on health
plans that fail to comply. For patients, this matters because delayed payments
often lead to disputes that affect billing.
The California Medical Association (CMA) highlights
similar concerns. They argue that health plans’ non-compliance undermines the
law’s intent and harms both physicians and patients. They strongly back
legislation to strengthen enforcement, encouraging providers to document delays
and report them. Patients, in turn, can rely on physician groups to advocate
for stronger accountability.
Tactical Advice: What Patients & Clinicians Should Do
Now
- Always
ask for a good-faith estimate. If a procedure is scheduled
three or more days in advance, you have the right to request one. Keep
written records and use them if your final bill is more than $400
above the estimate.
- Check
network status. Even in an in-network hospital, specialists like
anesthesiologists or radiologists may be out-of-network.
- Know
your rights in emergencies. You cannot be balance billed by
out-of-network providers in emergencies under the NSA.
- Use
the IDR process. If your insurer and provider cannot agree,
arbitration exists for resolution. Track timelines and outcomes carefully.
- Document
non-compliance. If health plans don’t pay within required timeframes,
escalate with regulators or legal support.
- Support
advocacy. Join groups pressing for expanded protections and stricter
enforcement.
- Ask
broader questions. Verify costs of ancillary services, follow-ups, and
network changes.
Real Stories & Failures
- Jessica’s
MRI bill: An inaccurate estimate left her with thousands in unexpected
charges despite new laws. Escalation was slow and unsatisfying.
- Emergency
case in Ohio: A teacher received a $2,700 bill after ER services
because certain protections hadn’t been fully implemented.
- Provider
struggles: Physicians often win arbitration but report that insurers
delay or refuse payment, creating financial strain.
Recent News: What’s Unfolding Right Now
- Congress
is pushing forward the No Surprises Act Enforcement Act (H.R. 4710
/ S. 2420), a bipartisan bill designed to address major compliance
problems. Specifically, the legislation would impose penalties on health
plans that don’t pay up after losing in Independent Dispute
Resolution (IDR) cases, and require additional reporting by agencies
overseeing the NSA. American Medical Association+2American College of
Radiology+2
- On September
8, 2025, House Republicans urged full implementation of the NSA’s
protections—pointing out that a key requirement, Advance Explanation of
Benefits (AEOB), remains largely unfulfilled. They wrote to the
federal departments (Labor, Treasury, HHS), asking them to accelerate
rules and enforcement so that patients actually receive estimates of
out-of-pocket expenses before scheduled care. Ways and Means+1
- The California
Medical Association (CMA) joined calls for stronger enforcement,
citing evidence that many health plans routinely ignore binding IDR
decisions—and that the current system fails to protect providers or
patients in practice. CMA-backed legislation is part of this wave of
initiatives seeking accountability. CMA Docs
- Imaging
societies, including the American College of Radiology, have raised
specific alarms. A recent article reported that radiology practices are
especially vulnerable, since delays or nonpayment under IDR rulings hit
them hard. The proposed enforcement bill is being watched closely by
imaging experts, who believe it could finally give “teeth” to what the NSA
intended. AuntMinnie
- A
survey by the Emergency Department Practice Management Association
revealed that 24% of emergency department practices reported that
their IDR awards were either unpaid or incorrectly paid beyond the
30 business-day deadline required by the NSA. That shows non-compliance is
not rare—it’s systemic. American Medical Association+1
Expert Tips for Clinicians and Health Administrators
- Train
billing teams on NSA requirements.
- Keep
detailed records of all estimates, patient communication, and insurer
responses.
- Track
arbitration decisions closely and escalate non-payment cases.
- Collaborate
with medical associations to build collective leverage for enforcement.
Myth-Busters: Clearing Common Misconceptions
- Myth:
The No Surprises Act protects all medical bills.
Reality: It covers many but not all situations. Some services, like ground ambulances, often remain outside the law’s scope. - Myth:
Good-faith estimates are guaranteed final costs.
Reality: Estimates are binding only in certain cases. They may not apply fully for insured patients until pending rules are finalized. - Myth:
Balance billing is completely illegal now.
Reality: It is banned only in specific situations—such as emergency care and out-of-network providers at in-network facilities. - Myth:
Arbitration guarantees fast payment.
Reality: Many insurers delay or avoid payments despite binding rulings, highlighting weak enforcement.
Legal, Practical, and Ethical Considerations of Surprise
Billing
Legal Implications
The No Surprises Act (NSA) fundamentally reshaped the
legal landscape of medical billing in the U.S. by prohibiting most balance
billing in emergency care and certain non-emergency situations. Yet, gaps
remain:
- Compliance
responsibilities. Providers and insurers are legally bound to honor
arbitration outcomes under the Independent Dispute Resolution (IDR)
process. Failure can expose them to regulatory penalties and, in
some cases, lawsuits.
- State
vs. federal overlap. Many states enacted surprise billing laws before
the NSA. Navigating conflicts between state-specific rules and
federal law is still a legal challenge for providers.
- Litigation
risk. Hospitals, insurers, and even patients may face lawsuits
stemming from disputed charges, unpaid arbitration awards, or contract
disputes. Case law will continue to refine how broadly protections apply.
Practical Considerations
Even when the law is clear, practical execution can be
messy:
- Administrative
burden. Providers face new costs in training staff, updating
billing software, and managing arbitration submissions. For small
practices, this strain can be significant.
- Insurance
delays. Patients often find that insurers slow-walk payments, leaving
providers without timely reimbursement and patients stuck in the middle.
- Patient
confusion. Despite legal protections, patients frequently lack
awareness of their rights, leading them to pay bills they might not owe.
Education and outreach remain critical.
- Operational
fixes. Hospitals and clinics must redesign workflows: verifying
network status earlier, issuing accurate good-faith estimates, and
improving billing transparency at intake.
Ethical Considerations
Beyond legal and practical issues, surprise billing raises
profound ethical questions:
- Trust
and transparency. Surprise bills undermine patient trust in the
healthcare system. Ethically, providers have a duty to communicate financial
risks upfront whenever possible.
- Equity
and access. Low-income patients are disproportionately harmed by
surprise bills. Ethical care requires ensuring protections are applied
fairly and consistently.
- Provider
responsibility. Clinicians may not personally issue bills, but they
share a duty to advocate for patients when billing practices cause harm.
- System
accountability. Ethically, the burden of fixing surprise billing
should not fall on patients alone. Providers, insurers, and policymakers
all share responsibility for fairness.
These three dimensions — legal, practical, and ethical
— remind us that solving surprise billing isn’t just about enforcing a statute.
It’s about aligning law, operations, and moral responsibility to rebuild trust
between patients and the healthcare system.
Frequently Asked Questions (FAQ)
Q1. What counts as a surprise bill?
Unexpected charges from out-of-network providers, often during emergencies or
at in-network hospitals, without your informed consent.
Q2. If I get a good-faith estimate, can I still be billed
more?
Yes. Protections are stronger for uninsured patients; insured patients still
face gaps. Bills exceeding the estimate by more than $400 may be
disputed in some cases.
Q3. What is IDR?
The Independent Dispute Resolution process lets arbitrators decide payment
disputes between insurers and providers.
Q4. Does the law cover ambulances?
Not consistently. Ground ambulance billing remains a major gap.
Q5. What if my insurer ignores the law?
Document everything, file complaints with regulators, and seek support from
advocacy groups or legal counsel.
Tools, Metrics & Resources Patients and Clinicians
Can Use
Understanding surprise billing isn’t just about
knowing the law — it’s about having the right tools, knowing which metrics to
track, and being able to access trusted resources quickly.
Tools for Patients
- Itemized
Billing Requests. Always request a line-by-line bill. This
prevents “bundling” errors and helps catch duplicate or miscoded charges.
- Good
Faith Estimate (GFE) Tracker. Keep a digital or paper copy of every
GFE you receive. Compare it against your final bill to spot overcharges.
- CMS
Complaint Form. Patients can file complaints about surprise bills
directly with the Centers for Medicare & Medicaid Services (CMS). This
form is online and can be submitted in minutes.
- Consumer
Assistance Programs (CAPs). Every state has CAPs that help patients
navigate disputes. They can assist with appeals, billing errors, and
insurance complaints.
Tools for Clinicians and Health Administrators
- Eligibility
Verification Systems. These confirm a patient’s network status before
care is delivered. Many electronic health record (EHR) systems now
integrate this step.
- Billing
Compliance Audits. Internal audits help practices track billing
disputes and measure compliance with the No Surprises Act.
- Arbitration
Submission Portals. For providers entering the Independent Dispute
Resolution (IDR) process, the federal portal is the central tool to
submit evidence.
- Staff
Training Modules. Practices should deploy ongoing training programs to
ensure registration staff and billing teams understand surprise billing
laws and workflows.
Metrics That Matter
Tracking the right metrics helps identify risks and measure
progress:
- %
of Out-of-Network Claims Disputed. A high rate signals systemic issues
with contracting or scheduling.
- Average
Resolution Time (days). How long disputes take from receipt of bill to
final resolution. Shorter = more efficient.
- Patient
Complaint Volume. Rising complaints suggest communication gaps or
billing transparency problems.
- Appeal
Success Rate. How often appeals result in reductions, reversals, or
insurer payment corrections.
- Collections
Avoided ($). Total dollar amount of bills reduced, corrected, or
avoided through dispute resolution.
Trusted Resources (Patients & Professionals)
- Centers
for Medicare & Medicaid Services (CMS) — No Surprises Help Desk
Offers FAQs, complaint forms, and live help for patients and providers.
CMS No Surprises Act Resource Center - Kaiser
Family Foundation (KFF)
Independent data and research on healthcare costs, patient protections, and billing reforms.
KFF Surprise Medical Bills Resource - Patient
Advocate Foundation (PAF)
Provides case management services, financial aid resources, and personalized help for patients facing medical debt.
Patient Advocate Foundation - American
Medical Association (AMA) Policy Hub
Guidance for providers navigating arbitration, billing compliance, and advocacy.
AMA Surprise Billing Resources
Step-by-Step Guide: What to Do If You Receive a Surprise
Bill
For Patients — immediate to 90-day playbook
- Pause
before paying. Don’t reflexively pay the bill. Instead, flag it and
start gathering evidence.
- Collect
the paper trail. Request and save an itemized bill, your
insurer’s Explanation of Benefits (EOB), any good-faith estimate
you received, dates of service, and the names of every provider who billed
for that visit. Save emails and note phone calls (date, time, person).
- Compare
the itemized bill to the EOB. Look for line items that were denied,
coded differently, or billed by out-of-network providers. Mark
discrepancies.
- Contact
the provider’s billing office. Ask politely for an explanation:
request an itemized bill, ask whether each provider was in-network,
and whether any financial assistance or discounts apply. Use a
short script: “I received invoice #[invoice number]. Please send an
itemized bill and confirm network status for every provider on this
invoice.”
- Contact
your insurer. Ask why the charge was processed out-of-network (if it
was). Request a written explanation and the steps to file an internal
appeal. Note the reference number for the call.
- Request
an internal appeal if appropriate. Follow the insurer’s appeal process
in writing and keep copies. Appeal timelines vary — act fast.
- Ask
about negotiation or financial assistance. If you owe money and the
provider is unwilling to reduce, ask for a payment plan, hardship
discount, or charity care application. Providers often prefer a negotiated
settlement to unpaid debt.
- Escalate
to external help. If the insurer and provider don’t resolve it, file a
complaint with your state insurance regulator and with CMS
when applicable. Document your complaint ID and follow up.
- Use
Independent Dispute Resolution (IDR) if available. If the NSA or state
rules apply and the provider and plan can’t agree, pursue IDR (or
other arbitration) where eligible. Keep your paperwork organized for the
arbitrator.
- Negotiate
last resort options. If IDR is not available or you lose, ask the
provider for a lump-sum discount, income-based reduction, or a reasonable
payment plan before letting it go to collections.
- Document
outcomes & learn. Save the final decision, payment confirmations,
and any written settlement. Note what went well and what failed so you can
help others (or your advocacy group).
- Share
your story. If you feel comfortable, share anonymized details with
consumer groups or media to help drive systemic change.
For Clinicians, Billing Teams & Health Administrators
— practical response steps
- Acknowledge
the patient immediately. When a patient reports a surprise bill,
respond within 24–48 hours and open a case file. Transparency builds
trust.
- Produce
and deliver an itemized bill. Supply an itemized statement and
the patient’s good-faith estimate (if one was provided). Document
who received the documents and when.
- Verify
network status for every billed provider. Confirm whether each
clinician who billed was in-network for that plan on the date of
service. Note any contract changes.
- Coordinate
with payer. Open a billing dispute with the insurer and track response
times. If the law applies, prepare to submit supporting documentation for IDR.
- Support
the patient through appeals. Offer guidance on internal appeals and
provide the information the patient needs to file complaints with
regulators.
- Track
IDR & enforcement timelines. Monitor arbitration outcomes and
whether payers comply. If the payer fails to remit, escalate internally to
legal or compliance and consider filing complaints with regulators.
- Use
cases to improve operations. Aggregate recurring surprise billing
incidents and fix root causes (e.g., credentialing, vendor contracts,
scheduling scripts, or estimate processes).
- Train
staff. Provide regular training on good-faith estimates,
advance notice requirements, and scripts for registration staff to reduce
future incidents.
Quick Checklist (Two-minute triage)
- Ask
for an itemized bill and the EOB.
- Confirm
each provider’s network status.
- Save
all communications and document everything.
- Start
insurer internal appeal process if needed.
- File
complaints with state regulator / CMS if unresolved.
- Consider
IDR or negotiate payment plan/discount.
Two Short Templates (copy & paste)
Email to provider billing office
Subject: Request — Itemized bill and network confirmation (Invoice #[#])
Body:
Hello — I received invoice #[invoice number] for care on [date]. Please send a
full itemized bill and confirm whether each provider who billed was in-network
for my plan ([insurer name], plan ID [#]) on the date of service. Also advise
whether financial assistance or a payment plan is available. Thank you. — [Your
name, DOB, contact]
Email to insurer (appeal start)
Subject: Appeal Request — Out-of-network charge (Claim #[#])
Body:
Hello — I am writing to appeal the processing of claim #[#] for care on [date].
Attached: itemized bill from provider, EOB, and good-faith estimate (if any).
Please advise the next steps and confirm receipt of this appeal. I request a
written explanation for the network determination. Thank you. — [Your name,
plan ID, contact]
10 Practical Rules of Thumb
- Always
demand written cost estimates.
- Verify
every provider’s network status.
- Review
insurance directories frequently.
- Ask if
any specialists involved will be out-of-network.
- Save
every document and email.
- Know
that IDR decisions should be enforced within ~30 days.
- Challenge
vague denials.
- Seek
help from advocacy groups.
- Be
cautious during insurance or provider changes.
- Stay
updated on legal reforms.
Where the System Still Needs Fixing
- Estimates
for insured patients are not yet fully binding.
- Ground
ambulance billing is often excluded.
- Enforcement
gaps allow insurers to ignore arbitration outcomes.
- Transparency
remains weak, with confusing contracts and fee schedules.
- Costs
may rise, as arbitration awards to large provider groups can push
premiums higher.
Call to Action
Patients: don’t wait for lawmakers—arm yourself with
knowledge and challenge unfair bills.
Providers: document every delay and stand together through associations.
Policymakers: close loopholes and strengthen enforcement so protections
are real, not theoretical.
Everyone: share stories, data, and experiences—transparency is the most
powerful tool.
Future Outlook: Where Surprise Billing Protections Are
Headed
Looking ahead, the landscape of surprise billing and patient
rights is still evolving. While the No Surprises Act has created a
stronger foundation, it is not the finish line.
Several trends are shaping what comes next:
- Stronger
enforcement mechanisms. Bipartisan bills in Congress aim to ensure
that insurers comply with arbitration rulings. If passed, patients and
providers may finally see faster and fairer resolution of billing
disputes.
- Expansion
of protections. Many experts believe the next frontier is ground
ambulance services, which currently remain one of the largest sources
of unexpected bills. Future legislation could close this loophole.
- Digital
transparency tools. Expect insurers and providers to face mounting
pressure to offer clearer, real-time cost estimates, possibly through
mobile apps or standardized platforms. Patients will increasingly demand
cost clarity at the click of a button.
- State
and federal coordination. States with existing surprise billing laws
are working to align their rules with federal protections. The result
could be a more uniform nationwide framework, reducing confusion for
patients.
- Litigation
and case law. As disputes escalate, courts will shape how the law is
interpreted—clarifying gray areas and setting precedents that influence
both policy and practice.
- Patient
advocacy momentum. With growing awareness, more patients are sharing
their stories online and pushing for reform. Grassroots pressure is likely
to accelerate policy updates.
The future of billing fairness will depend not just
on lawmakers, but also on the collective action of patients, clinicians, and
advocates who demand accountability and transparency.
Final Thoughts
The No Surprises Act is progress, but not perfection.
It reduces many unexpected costs but leaves gaps. Patients and providers must
remain proactive, informed, and vocal. Surprise billing should not be a
recurring nightmare—but for now, it still is.
References
- Medical
Economics — “No Surprises Act cut patients’ out-of-pocket costs by
about $600 a year.” (Link)
- American
Medical Association — “One wrinkle in surprise billing law: Health
plans aren’t paying.” (Link)
- California
Medical Association — “CMA-backed legislation would strengthen
enforcement of surprise billing protections.” (Link)
About the Author
Dr. Daniel Cham is a physician and medical consultant with
expertise in medical tech consulting, healthcare management, and medical
billing. He focuses on delivering practical insights that help professionals
navigate complex challenges at the intersection of healthcare and medical
practice. Connect with Dr. Cham on LinkedIn: linkedin.com/in/daniel-cham-md-669036285
Disclaimer / Note
This article provides an overview and does not constitute
legal or medical advice. Readers should consult qualified professionals for
specific guidance.
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#PatientRights #NoSurprisesAct #HealthcarePolicy
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#InsuranceTransparency #PhysicianAdvocacy #ConsumerHealth
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