Compliance is Critical: What Physicians Must Tell Their Billing Staff About the No Surprises Act

The No Surprises Act (NSA), which became effective on January 1, 2022, fundamentally changed healthcare billing by protecting patients from certain unexpected medical bills. For physicians, compliance is not optional; it requires a complete overhaul of billing and patient communication processes.  

A physician's key directive to their billing company or office staff should focus on three crucial areas to ensure full compliance and avoid penalties: the ban on balance billing, the requirement for Good Faith Estimates (GFEs), and the process for payment disputes.

1. Zero Balance Billing for Protected Services

The most immediate change for billing staff is the strict ban on balance billing in specific scenarios, meaning the patient cannot be charged for the difference between the provider’s charge and the amount paid by the insurance plan.  

·         Emergency Services: Patients can only be billed for their standard in-network cost-sharing amount (like a copay or deductible) for most emergency care, even if the physician or facility is out-of-network. This protection also generally extends to post-stabilization care until the patient is stable and can consent to further out-of-network care.  

·         Non-Emergency Services at In-Network Facilities: Patients are protected from balance billing when they receive scheduled, non-emergency care from an out-of-network provider (such as an anesthesiologist or radiologist) at an in-network hospital or ambulatory surgical center.  

·         Patient Responsibility: In all protected situations, the billing staff must only charge the patient their in-network cost-sharing amount. The provider and the insurer must resolve the payment dispute directly.  

·         Required Notice: Staff must ensure the required disclosure notice explaining the patient’s protections against balance billing is prominently posted at the facility, on the practice website, and provided to

2. Mandatory Good Faith Estimates (GFEs)

For patients who are uninsured or self-pay (not using insurance for a service), the physician's staff is required to provide a Good Faith Estimate (GFE) of the total expected charges.  

·         Who Needs a GFE? Any patient who is uninsured or who is choosing not to use their health insurance for a scheduled service.  

·         What Must it Include? The GFE must be itemized, detailing all anticipated services and expected costs from the primary provider ("convening provider") and any other providers ("co-providers") involved in the care, such as labs or imaging.  

·         Strict Timelines:

o    If the service is scheduled at least 10 business days in advance, the GFE must be provided within 3 business days of scheduling.  

o    If the service is scheduled at least 3 business days in advance, the GFE must be provided within 1 business day of scheduling.  

o    If a patient simply requests a GFE, it must be provided within 3 business days of the request.  

·         Dispute Resolution: Staff must be trained to inform patients that they can dispute a final billed amount if it is $400 or more than the amount stated on the GFE.   p

3. Out-of-Network Payment Dispute Process

When balance billing is prohibited, the financial dispute is shifted from the patient to the payer (insurance company). Billing staff must be prepared to follow the formal process for payment disagreements.  

·         Initial Steps: After submitting a clean claim, the health plan must send an initial payment or notice of denial to the provider within 30 days.  

·         Open Negotiation: If the provider disagrees with the payment amount, they must initiate a 30-day open negotiation period with the health plan.  

·         Independent Dispute Resolution (IDR): If open negotiation fails, the billing staff or company must be ready to initiate the federal Independent Dispute Resolution process (IDR). This is a "baseball-style" arbitration where both the provider and the plan submit a final payment offer, and a certified IDR entity selects one of the two amounts. Staff must be prepared to provide supporting documentation to justify the practice's payment offer.  

Summary for Staff Training

The physician should stress that the billing team's primary role is to ensure the patient is taken out of the middle of all payment disputes covered by the NSA. Staff training must cover:

1.      Patient Identification: How to identify which patients and services are protected by the NSA.

2.      Billing Procedure: Banning balance bills for all protected services and correctly applying in-network cost-sharing.  

3.      Documentation: Strict adherence to GFE timelines and documentation requirements for uninsured/self-pay patients.  

4.      Dispute Management: The formal steps for engaging in open negotiation and the IDR process with payers.  

Failure to comply with the NSA can result in significant financial penalties, making robust internal processes and ongoing staff education essential. More resources can be found on the Centers for Medicare & Medicaid Services (CMS) No Surprises Act Overview.