Regulatory Resources for Surprise Billing

December 12, 2021

Navigating the No Surprises Act in 2022

The No Surprises Act addresses some of the most pressing medical-affordability concerns facing American families by helping patients understand and predict their out-of-pocket costs. It also has great repercussions for providers.

Beginning Jan. 1, 2022, providers and facilities are prohibited from billing out-of-network patients more than in-network, cost-sharing amounts in emergency and certain non-emergency situations. For patients without health insurance, providers will need to notify the patient in advance to provide a good faith estimate of expected charges for scheduled services.

The No Surprises Act also creates dispute-resolution processes for plans and out-of-network providers, and for self-pay patients and providers.

The Act has three major impacts for providers and facilities:

Billing statement example

Balance billing:

Providers and facilities are prohibited from billing out-of-network patients more than in-network, cost-sharing amounts in certain circumstances. The prohibition applies to both emergency and certain non-emergency situations where patients do not have the ability to choose an in-network provider. In some cases, providers or facilities may be able to obtain the patient’s advance written consent to balance billing.

A man and woman looking at billing statement papers.

Good faith estimates:

Uninsured patients including both patients with no health insurance coverage and patients who are choosing not to use their health insurance or “self-pay” are entitled to a good faith estimate of expected charges. When an uninsured individual schedules an item or service, they will receive the good faith estimate directly from the applicable providers and facilities.

Man shaking hand and smiling

The No Surprises Act covers two types of dispute resolution. The independent dispute resolution process allows a non-contracting provider or payer to dispute whether the specified rate was appropriate. The selected dispute resolution process applies to payment disputes between an uninsured patient and provider when the patient receives a bill for more than $400 in excess of that patient’s good faith estimate of expected charges.


Other general information:

As a trusted partner to healthcare providers, R1’s Advisory and Assurance Regulatory team is well positioned to lend its expertise on this legislation and its impacts for providers. Be sure to check back regularly for updates.


Subscribe to our email list to get the latest in your inbox