The No Surprises Act and out-of-network claims: what practices need to know

The No Surprises Act took effect on January 1, 2022. Its headline purpose is patient protection: people should not receive surprise bills for care they could not reasonably have chosen in-network. For providers, it also created a structured process for how certain out-of-network claims are paid and disputed. Both halves matter for revenue.

What it covers

• Emergency services, regardless of whether the facility or the clinician is in the patient's network.
• Non-emergency services delivered by out-of-network clinicians at in-network facilities, with limited exceptions where the patient gives informed consent in advance.
• Air ambulance services from out-of-network providers.

For covered services, the patient's cost-sharing is limited to what it would have been in-network, and the provider cannot balance bill for the difference. State laws may add protections for fully insured plans, so the applicable rule depends on the plan type and the state.

How payment works

After receiving a clean claim for a covered out-of-network service, the plan is required to send an initial payment or a notice of denial within 30 calendar days. If the provider disagrees with the amount, it can start a 30-business-day open negotiation period with the plan. If the parties still cannot agree, either side can initiate the federal Independent Dispute Resolution process within the window that follows open negotiation. A certified IDR entity then selects one of the two offers, taking into account factors that include the qualifying payment amount, which is generally based on the plan's median contracted rate.

What this means operationally

• Out-of-network status has to be identified at eligibility, before the visit, so the practice knows which rules will apply to the claim.
• Initial payments should be compared against benchmark data and the practice's fee schedule rather than accepted by default.
• Open negotiation and IDR deadlines are short and unforgiving. They need to be tracked the same way timely-filing limits are.
• Documentation of the service, the setting, and the network status of the facility decides whether a claim falls under the Act at all.
• Uninsured and self-pay patients are entitled to a good-faith estimate before scheduled care, which is a front-office process, not a billing one.

Where negotiation still happens outside the Act

Many out-of-network claims are not covered by the No Surprises Act, for example elective care a patient knowingly chose out of network. For those, single-case agreements negotiated before care, and post-adjudication negotiation on the payer's offer, remain the tools that set a defensible rate. The right approach is decided claim by claim, which is why out-of-network work benefits from a dedicated process rather than being folded into general A/R.

The Act did not make out-of-network care unpayable. It made the process more structured, and structure rewards practices that track it.