When the No Surprises Act first took effect in 2022, many Americans hoped it would finally put an end to unexpected medical bills. The law was designed to protect patients from surprise charges, improve price transparency, and make it easier to resolve billing disputes.
A new final rule has now been released, and while it includes some positive changes, it also reveals several important gaps and loopholes that consumers should understand.
If you rely on health insurance to help manage medical costs, these are the biggest issues you need to know about.
Quick Refresher: What Is the No Surprises Act?
The No Surprises Act was passed in 2020 and took effect in January 2022. It was designed to protect patients from certain unexpected medical bills, especially when they receive care from out of network providers without realizing it.
Some of the law’s major protections include:
- Protection from many surprise out of network charges during emergencies
- Protection when an out of network provider works at an in network facility
- Good faith estimates for some medical services
- A dispute resolution process for billing disagreements
Although these protections remain in place, the new rule highlights several limitations that many consumers may not realize exist.
1. Ground Ambulance Bills Are Still Not Protected
One of the biggest gaps in the law is that ground ambulance services are largely excluded.
The No Surprises Act protects patients from many surprise air ambulance bills, but it does not provide the same protections for most ground ambulance rides.
This means you could still receive a large out of network bill after an emergency ambulance trip.
2. The Cost to File a Billing Dispute Dropped Dramatically
The new rule lowers the fee to file certain medical billing disputes from $115 to $15.
While this sounds like good news, some consumer advocates worry that lower fees may encourage large companies to file even more disputes, potentially increasing delays throughout the system.
3. Millions More Disputes Than Expected
Federal officials originally expected roughly 17,000 disputes per year.
Instead, the system has received millions of disputes since implementation, creating significant backlogs and delays.
4. Companies Don’t Have to Explain Why They Are Filing Disputes
Earlier proposals would have required parties initiating a dispute to explain why negotiations failed.
That requirement was removed from the final rule.
As a result, disputes can be filed without providing a detailed explanation.
5. No Clear Standard for Good Faith Negotiations
Before arbitration can occur, insurers and providers are supposed to negotiate.
However, the rule does not clearly define what meaningful participation looks like during that process.
Critics argue this could allow parties to go through the motions without genuinely trying to reach an agreement.
6. No New Penalties for Insurers That Break Transparency Rules
Advocates requested stronger financial penalties for insurers that fail to comply with transparency requirements.
The final rule does not create new enforcement penalties.
7. No Penalties for Flooding the System With Invalid Claims
Officials have acknowledged that many disputes are ultimately found to be ineligible.
Despite concerns about excessive filings, the rule does not create additional penalties for submitting ineligible claims.
8. Your Insurance Card Doesn’t Have to Explain Your Rights
The government considered requiring insurers to print information about surprise billing protections directly on insurance ID cards.
That requirement was not included in the final rule.
Consumers may need to research their rights independently.
9. There Are Still No Standard Price Caps
Some advocates wanted fixed benchmark rates that would limit how much out of network providers could collect.
The final rule continues to rely largely on arbitration instead.
10. Your Premiums Could Still Increase
Consumer groups warn that higher arbitration awards and increased dispute activity could eventually contribute to higher insurance costs.
Whether that occurs remains to be seen, but it remains a concern raised by advocates.
11. You Can Still Sign Away Some Protections
This is one of the most important issues for consumers.
In certain non-emergency situations, providers can use a “notice and consent” process.
If you sign the form, you may give up some of your surprise billing protections and become responsible for additional out of network charges.
Always read paperwork carefully before signing.
Ask:
- Is this provider in network?
- Am I waiving any billing protections?
- Could I owe additional charges if I sign?
12. Medicare and Medicaid Beneficiaries Are Not Covered by These Dispute Rules
The federal dispute process primarily applies to certain commercial insurance plans.
People with Medicare and Medicaid generally rely on separate billing protections.
If you have Medicare and need help understanding your options, our partner Chapter offers free Medicare guidance. You can learn more here: https://lirlinks.com/chapter or call (417) 319-2139.
13. Patients Still May Not Receive Clear Billing Codes
The rule requires insurers to use standardized codes when communicating with providers.
However, those same explanations may not appear clearly on documents sent to patients.
As a result, Explanation of Benefits forms may remain confusing.
14. The Backlog Problem Has Not Been Solved
The government has taken steps intended to improve efficiency, including allowing certain claims to be grouped together.
However, significant backlogs remain.
15. There Is No Guarantee of Fast Resolution
Because the dispute system is handling far more cases than expected, patients and providers may still face lengthy delays.
16. Disputes Can Be Rejected Without a Detailed Explanation
The final rule does not require arbitrators to provide detailed written explanations when a dispute is deemed ineligible.
This can leave participants uncertain about what went wrong.
17. There Is No Formal Appeals Process
If a dispute is rejected, there is generally no dedicated appeals process within the federal dispute system.
Instead, affected parties may need to contact the No Surprises Help Desk or file a complaint.
What Should You Do If You Receive a Surprise Medical Bill?
There are still important protections available.
If you receive an unexpected bill:
- Verify whether your health plan qualifies for No Surprises Act protections.
- Review all paperwork carefully before signing.
- Keep copies of bills, estimates, and insurance documents.
- Contact your insurer and provider immediately if charges seem incorrect.
- Visit CMS.gov/nosurprises to learn about your rights.
- Contact the No Surprises Help Desk if you believe protections were violated.
Relief Recap
The No Surprises Act still provides important protections against many unexpected medical bills. However, the new final rule reveals several significant limitations that consumers should understand.
Ground ambulance bills remain largely unprotected. Some patients can accidentally waive their rights by signing forms. Medicare and Medicaid beneficiaries are not covered by this specific dispute process. And the system continues to struggle with massive backlogs.
Understanding these gaps can help you avoid costly surprises and make more informed decisions about your medical care.
Disclaimer: The views and opinions expressed in the content are solely those of the content creators and do not necessarily reflect the views, opinions, or positions of the Social Security Administration, Medicare, Chapter, or its affiliates. Chapter makes no representations or warranties regarding the accuracy, completeness, or reliability of the information provided. All content is intended for informational, educational, or entertainment purposes only and should not be interpreted as official positions of the Social Security Administration, Medicare, Chapter, or its affiliates. Chapter disclaims any liability for actions taken based on this content.
If you need assistance with Medicare, please reach out to Medicare, your local State Health Insurance Program (SHIP), your current Medicare insurance agent/broker/plan, or contact our Medicare partner, Chapter, at 417-319-2139 or visit their website at https://lirlinks.com/chapter. Chapter: Memoir, Inc. d/b/a Chapter is a privately owned, data- and technology-enabled advisory service helping older Americans navigate retirement. Insurance agency services are provided by Chapter Advisory, LLC, a licensed health insurance agency and wholly owned subsidiary of Memoir, Inc. In California, Chapter Advisory, LLC does business as Chapter Insurance Services (Lic. No. 6003691).
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