No Surprises Act compliance: what providers actually have to do
The balance billing ban, good faith estimates, consent rules, and disclosures, translated from the regulations into a working checklist.
No Surprises Act compliance comes down to four obligations, and most groups are shaky on at least one. This site lays out what the law requires of providers and facilities, where the penalties sit, and the part most compliance checklists skip: the same law that restricts your billing gives you an arbitration process that pays.
All 3.39 million federal IDR disputes published by CMS, 2023 through 2025. Explore the data at idrexplorer.com.
No Surprises Act compliance for providers means four things: do not balance bill protected patients beyond their in-network cost sharing, give uninsured and self-pay patients a good faith estimate on the required timeline, use the notice-and-consent process only where the law allows it, and post and distribute the required disclosures. Violations carry civil monetary penalties of up to $10,000 each, enforced by states first and CMS as backstop.
The four obligations
1. The balance billing ban. For emergency services and for out-of-network care at in-network hospitals and ambulatory surgery centers, you may only collect the patient's in-network cost sharing. The rest of your payment comes from the plan, and disputes over that amount go to arbitration, not to the patient.
2. Good faith estimates. Uninsured and self-pay patients must get a written estimate of expected charges, on deadlines tied to when care was scheduled. Blow the estimate by $400 or more and the patient can take the bill to the patient-provider dispute resolution process.
3. Notice and consent, only where allowed. For some scheduled out-of-network care at in-network facilities, a patient can waive protections by signing the standard notice at least 72 hours ahead. For emergency services and ancillary specialties, consent is never valid, no matter what the patient signs.
4. Disclosures. Providers and facilities must post the standard notice of No Surprises Act protections publicly, put it on their website, and give it to the patients those protections cover.
Good faith estimate deadlines
The deadlines run from scheduling: care scheduled at least 10 business days out requires the estimate within 3 business days of scheduling; care scheduled 3 to 9 business days out requires it within 1 business day; and anyone who asks for an estimate must get one within 3 business days. The estimate must list expected items and services with codes and expected charges. The GFE requirements page has the full breakdown.
When you can and cannot balance bill
The notice-and-consent exception is narrow and the never-waivable list is long: anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, and diagnostic services including lab and imaging can never balance bill protected patients at in-network facilities, with or without a signed form. Emergency care before stabilization can never be waived either. The consent rules page covers the timing, the standard form, and the common mistakes.
Penalties and enforcement
Providers face civil monetary penalties of up to $10,000 per violation. States are the primary enforcers, with CMS enforcing directly in states that do not act. There is a safe harbor for honest mistakes: withdraw the improper bill and refund the patient with interest within 30 days. Details on the penalties page.
Compliance does not get you paid
Everything above keeps you out of trouble. The same No Surprises Act that bans balance billing gives providers a federal arbitration process for underpaid protected claims, and the published record shows providers win 85.8 percent of decided disputes at a typical award around 4.7 times the qualifying payment amount. If your group absorbs the billing restrictions without working the payment side, you are using half the law. Lido IDR files those disputes for a flat fee per arbitration.
Common questions
What does the No Surprises Act require providers to do?
Four things: honor the balance billing ban for protected emergency and facility-based care, give uninsured and self-pay patients good faith estimates on deadline, use notice-and-consent waivers only where the law allows them, and post and distribute the standard disclosure of patient protections.
Do good faith estimates apply to insured patients?
Enforcement today covers uninsured and self-pay patients. The No Surprises Act also contemplates estimates flowing to plans for insured patients through advanced explanations of benefits, but that piece remains deferred pending rulemaking, so the operational requirement is for uninsured and self-pay patients.
Which services can never balance bill, even with consent?
Emergency services before stabilization, and ancillary services at in-network facilities: anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, and diagnostic services including lab and imaging. A signed consent form does not make these billable.
What are the penalties for violating the No Surprises Act?
Civil monetary penalties of up to $10,000 per violation for providers. States enforce first; CMS enforces in states that do not. A safe harbor protects providers who withdraw an improper bill and refund the patient with interest within 30 days.
Does complying with the No Surprises Act mean accepting whatever the plan pays?
No. The ban is on billing the patient, not on disputing the plan. Underpaid protected claims go to federal IDR, where providers won 85.8 percent of published decisions at a typical award around 4.7 times the qualifying payment amount.
Talk through your numbers
Book 30 minutes with an NSA/IDR specialist. Bring your payer mix and rough out-of-network claim volume, and we will walk through which claims are eligible, what similar providers are winning at IDR, and what a flat fee arrangement looks like. Three quick questions, then pick a time.
Which best describes you?
Roughly how many out-of-network claims does your group bill a month?
An estimate is fine.
Who works your out-of-network claims today?
Last step, then pick a time.
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This page is for medical providers
If you got a surprise medical bill, you do not need a service like ours. The federal No Surprises Act protects you directly, and government help is free.
Start here: cms.gov/medical-bill-rights
No Surprises Help Desk: 1-800-985-3059