Balance billing is when a medical provider bills you for the difference between what they charge and what your insurance agrees to pay. If a provider charges $100 for a service but your insurer’s allowed amount is $70, the provider can send you a bill for the remaining $30. Before federal protections took effect in 2022, nearly one in five insured adults reported receiving these surprise bills after emergency visits or in-network hospital stays that involved out-of-network providers.
How Balance Billing Works
Every health insurance plan negotiates rates with providers who join its network. When you see an in-network provider, they’ve agreed to accept the insurer’s allowed amount as full payment (minus your copay or deductible). Out-of-network providers have no such agreement. They can charge whatever they want, and your insurer will only reimburse up to its allowed amount. The gap between those two numbers lands on you.
This gap can be modest or staggering depending on the service. Before federal law stepped in, studies found that roughly 1 in 5 patients having elective surgery with an in-network surgeon at an in-network facility still received an out-of-network bill, averaging over $2,000 more than insurance would typically pay. Surgical assistants charged an average of $3,600 above insurance rates, anesthesiologists $1,200, and in some orthopedic cases, neurologists billed over $18,000 for monitoring during spinal operations. One widely reported case involved a $41,212 surprise bill for an emergency appendectomy.
The No Surprises Act
The No Surprises Act, which took effect January 1, 2022, is the main federal law protecting patients from balance billing. It covers three core scenarios:
- Emergency services. Nearly all emergency care, including emergency mental health services, plus any treatment needed to stabilize you afterward, regardless of which department you end up in.
- Out-of-network providers at in-network facilities. If you go to an in-network hospital, outpatient department, or ambulatory surgical center but are treated by an out-of-network provider you didn’t choose (a common scenario with anesthesiologists, radiologists, and assistant surgeons), you’re protected.
- Air ambulance services. Out-of-network air ambulance providers cannot balance bill you.
Under these protections, you only owe your normal in-network cost sharing (copay, coinsurance, or deductible). The provider and your insurer work out the rest between themselves. This applies even if your plan has a closed network that normally offers zero out-of-network coverage.
What the Law Does Not Cover
The No Surprises Act does not protect you when you voluntarily receive non-emergency care from an out-of-network provider at an out-of-network facility. If you schedule a procedure at a surgery center that isn’t in your plan’s network, the provider can still balance bill you.
Ground ambulances are the most notable gap. While air ambulances are covered, ground ambulance providers face no federal restrictions on balance billing. Some states have their own protections for ground ambulances, but coverage varies widely. The law also does not apply to people on Medicare, Medicaid, or who are uninsured, since those groups are covered under separate rules.
When You Can Waive Your Protections
In limited situations, an out-of-network provider can ask you to waive your balance billing protections and agree to pay higher charges. This is only allowed for scheduled, non-emergency services (not ancillary services like lab work) at in-network facilities, or for certain post-stabilization services. It is never allowed for emergency care.
The rules around these waivers are strict. The notice and consent form must be a standalone document, physically separate from all other paperwork. A representative of the provider must be present or available by phone to explain the form and answer your questions. The form must include a good-faith cost estimate, and it cannot be modified by the provider beyond specific bracketed fields.
Timing matters too. If you schedule the appointment at least 72 hours in advance, you must receive the notice at least 72 hours before the service. If you schedule within 72 hours, you must get the notice on the day you schedule. And if the form is given on the day of service itself, it must come at least 3 hours before the procedure. You are never required to sign. Refusing the waiver means the provider must treat you under normal balance billing protections or refer you to an in-network alternative.
How Providers and Insurers Settle the Difference
When the No Surprises Act applies, the financial dispute stays between the provider and the insurer. You pay your in-network share and nothing more. Behind the scenes, the process works in stages.
First, the two parties enter a 30-business-day open negotiation period to try to agree on a payment amount. If they can’t reach an agreement, either side has 4 business days to initiate the federal Independent Dispute Resolution (IDR) process. A neutral third-party arbitrator, chosen from a list of certified organizations, reviews payment offers from both sides and picks one. There’s no splitting the difference: the arbitrator selects one party’s offer as the final amount. Both sides must accept the decision, and payment is due within 30 calendar days. The parties can also settle at any point before the arbitrator rules.
None of this process involves the patient. Your bill is already settled at the in-network rate.
What to Do if You Get a Surprise Bill
If you receive a bill you believe violates the No Surprises Act, start by gathering your medical bill, insurance card, explanation of benefits, and any notice-and-consent forms you were given. Digital copies or photos of these documents are fine.
You can file a complaint with the No Surprises Help Desk by calling 1-800-985-3059. The help desk offers support in English, Spanish, and over 350 other languages. You can also submit a complaint online through the CMS complaint portal, where you’ll be prompted to upload your documentation. After you file, expect a response within 60 days if additional information is needed. Keep your confirmation number to check on your complaint’s status.
In the meantime, do not ignore the bill, but don’t pay the balance-billed amount either. Contact the provider’s billing department and let them know you believe the charge is covered under the No Surprises Act. Many billing disputes resolve once the provider’s office reviews the situation, especially when the patient can identify the specific protection that applies.