Surprise medical bills are illegal now: the No Surprises Act, what you owe, and how to get an out-of-network bill canceled
Since 2022, you can't be billed more than your in-network cost-sharing for emergency care, for out-of-network doctors at in-network hospitals, or for air ambulances. Uninsured patients get a Good Faith Estimate and can dispute bills that exceed it by $400. Which bills are covered, which aren't (ground ambulances, consent waivers), and the complaint that makes providers cancel the charge.
- The No Surprises Act (in force since January 1, 2022) bans balance billing in three situations: emergency care (any ER, in or out of network, including post-stabilization until you can be safely moved), out-of-network providers at in-network facilities (anesthesiologists, radiologists, pathologists, assistant surgeons, hospitalists), and air ambulances.
- In those cases you owe only your in-network deductible, copay, and coinsurance. The provider and insurer settle the rest between themselves.
- Uninsured or self-pay: you're entitled to a Good Faith Estimate before scheduled care. If the final bill is $400 or more above the estimate, you can start a federal patient-provider dispute for $25 and an independent reviewer sets the price.
- Not covered: ground ambulances (some states cover them), care you scheduled out of network knowingly, and cases where you signed a valid consent waiver (allowed only for some non-emergency services, given 72 hours in advance, never for emergency or ancillary providers).
- Got billed anyway? Tell the provider it violates the NSA, complain to CMS at 1-800-985-3059 or online, and don't pay the balance.
Which bills are covered
Swipe the table sideways to see every column.
| Situation | Covered by the NSA? | You owe |
|---|---|---|
| Emergency room visit at an out-of-network hospital | Yes | In-network cost-sharing only |
| Out-of-network anesthesiologist / radiologist / lab at an in-network hospital or surgery center | Yes (no waiver allowed for these) | In-network cost-sharing |
| Out-of-network surgeon at in-network hospital, you signed a consent form 72+ hours before | Not covered if waiver valid | What you agreed |
| Air ambulance | Yes | In-network cost-sharing |
| Ground ambulance | No federally (about 20 states have their own rules) | State-dependent |
| Uninsured, scheduled care, final bill $400+ over the Good Faith Estimate | Dispute right | The amount the reviewer decides |
| Out-of-network care you chose at an out-of-network facility | No | Provider's rate |
Also protected: the ER's follow-up "post-stabilization" services, and your insurer must count NSA cost-sharing toward your in-network deductible.
What to do when a surprise bill arrives
- Match it to the EOB. If the bill is higher than the "patient responsibility" on your insurer's EOB for a covered situation, it's balance billing.
- Call the provider's billing office and say: "This is an emergency / ancillary service covered by the No Surprises Act. I'm only responsible for in-network cost-sharing. Please correct the bill." Many drop it here.
- Write to the provider (keep a copy) stating the same and asking them to hold the account.
- Call your insurer and ask them to reprocess the claim under the NSA if they paid it as out-of-network.
- Complaint: CMS No Surprises Help Desk, 1-800-985-3059, or online at cms.gov/nosurprises. CMS investigates and providers face penalties up to $10,000 per violation; most fix the bill when the complaint lands. Also your state insurance department if the plan is state-regulated.
- Never pay the disputed balance while it's under review; pay your legitimate cost-sharing to show good faith.
Uninsured: the Good Faith Estimate dispute
If you're uninsured or self-pay and scheduled care at least 3 days ahead, the provider must give a written Good Faith Estimate (GFE). If the bill from that provider is $400 or more above the GFE:
- Within 120 days of the bill, file the patient-provider dispute resolution request with CMS (online form), pay the $25 fee.
- An independent entity reviews; if it sides with you, you pay the GFE amount (or less), and the $25 is credited.
- During the dispute the provider can't send you to collections.
No GFE was given at all? That's a violation; report it to CMS, and use it as leverage in negotiating the bill.
FAQ
The hospital was in-network but the ER doctor's group billed me $1,800
Classic NSA case. You owe in-network cost-sharing only. Tell the group, then CMS.
I signed papers at admission; did I waive protection?
Admission paperwork can't waive NSA protections, and waivers are never valid for emergencies or for anesthesia, radiology, pathology, lab, neonatology, or assistant surgeons.
My plan is through my employer and self-funded
Still covered; the NSA applies to employer plans, marketplace plans, and individual plans. Medicare and Medicaid already banned balance billing.
Ground ambulance bill of $2,500
Not federally protected. Check your state (CA, CO, NY, TX and others limit ambulance balance billing), ask the ambulance company for their Medicare rate, and negotiate; many settle at a fraction.