The No Surprises Act: What You Need to Know

We have continued to monitor the No Surprises Act and have established a plan for how HST’s patient estimates can help providers address the disclosure and consent requirements.

What makes things tricky is that this law is complex, broad, and still developing in several areas. Many core protections have been in effect since January 1, 2022, while other provisions continue to rely on agency guidance, enforcement discretion, or future rulemaking. It is also important to highlight that while hospitals, hospital outpatient departments, and payers receive substantial attention in the law, ASCs are not exempt from applicable requirements.

The law has become a central part of billing transparency in healthcare. It affects how patients receive cost information, how providers communicate network status, how health plans display benefits, and how payment disputes are handled when out-of-network care is involved.

Although the No Surprises Act is sometimes described as a healthcare transparency bill, it is more accurately a collection of consumer protections, provider duties, plan requirements, and dispute resolution processes within the Consolidated Appropriations Act, 2021. 

Please know the No Surprises Act is evolving, and we will update this post as needed. 

Background

Momentous changes have taken place regarding provider and payor responsibilities and patients’ rights related to financial responsibility. This article summarizes important aspects of this complex and broad law, including requirements that are already in effect and provisions that are still being implemented.

We encourage our clients to understand how the law affects their operations, identify which duties apply to their center, and maintain a documented compliance process.

The major balance billing protections are now established, but several transparency provisions still do not have complete implementing regulations. For example, the Advanced Explanation of Benefits requirement for insured patients has not yet been fully implemented or enforced.

Health plans and providers should continue to monitor CMS and Department of Labor guidance rather than assuming every statutory provision operates through a finalized technical process. 

For teams researching No Surprises Act insurance responsibilities, the most important starting point is to separate the duties of providers and facilities from those of group health plans and health insurance issuers.

A surgery center cannot control the content of a payer’s identification card or the payer’s public directory. Still, it does have responsibilities to provide accurate information, follow balance billing restrictions, issue required notices, and support patients with reliable financial information.

What’s Required?

How will hospitals, hospital outpatient departments, ASCs, surgeons, anesthesia providers, and other ancillary providers be impacted? Here are key items to consider, how HST’s patient estimates can assist, and brief highlights from the law and current CMS guidance.

State law remains important because some states provide protections or enforcement approaches that are more protective than the federal rules. Centers should review both federal requirements and the rules that apply in each state where they operate.

The No Surprises Act provider requirements are not limited to one form or one department. Compliance can involve registration, scheduling, insurance verification, contracting, patient estimates, website content, payment collection, coding, billing, refunds, payer communication, record retention, and complaint response.

A center should map each requirement to a responsible role and a repeatable workflow.

Disclosures

Applicable providers and facilities must make information about patient protections against surprise billing publicly available. The notice should be displayed prominently at a publicly accessible location in the facility, such as an area where patients schedule care, check in, or pay bills.

The disclosure or a link to it must also appear on a searchable homepage of the provider’s or facility’s public website. CMS provides a model disclosure notice and instructions. 

The No Surprises Act disclosure requirements are broader than merely placing a poster in the lobby. The content must explain applicable federal and state balance billing protections, describe how a patient can report a suspected violation, and remain accessible to people with disabilities and individuals who need language assistance.

Facilities should verify that website links work, posted notices remain visible, and staff know when and how the individual notice is delivered.

A practical approach is to build the notice into the registration and payment workflow while keeping it distinct from consent to waive protections. A disclosure notice informs patients of their rights. It does not mean the patient has agreed to out-of-network billing, and it does not require a patient signature simply to acknowledge receipt. 

Insurance Verification

You are responsible for requesting and confirming the patient’s insurance coverage.

The statute also contemplates a future process in which providers send a good faith estimate for an insured individual to the health plan so the plan can provide an Advanced Explanation of Benefits. That process has not yet been fully implemented or enforced.

Providers should monitor future rulemaking and data exchange standards instead of building a workflow around an assumed deadline that is not currently operational. 

Insurance verification should confirm more than whether a policy appears active. Staff should review:

• The specific plan
• Network participation
• Effective dates
• Benefit design
• Deductible and coinsurance
• Prior authorization requirements
• The participation status of the facility and known providers

Patients should be told that verification is based on information available at the time and is not a guarantee of payment.

Provide Patient Estimates

You must provide uninsured and self-pay patients with a Good Faith Estimate that follows HHS requirements when the individual schedules qualifying care far enough in advance or requests cost information.

The estimate must be written in clear and understandable language and delivered on paper or electronically in a format the patient can save and print. A Good Faith Estimate is not a consent form, and a patient does not have to waive legal protections to receive one.

Information about the availability of estimates must be accessible and available in appropriate languages and formats.

The No Surprises Act Good Faith Estimate requirements use business-day timing rules, not the 72-hour and three-hour timing rules that apply to certain notice and consent documents.

When uninsured or self-pay care is scheduled three to nine business days in advance, the estimate must generally be provided within one business day after scheduling.

When care is scheduled 10 or more business days in advance, the estimate must generally be provided within three business days after scheduling.

If an uninsured or self-pay individual requests an estimate before scheduling, the provider or facility must generally provide it within three business days.

A person who schedules care only zero to two business days in advance is not entitled to a Good Faith Estimate based solely on scheduling. 

Accuracy matters, but a Good Faith Estimate is still an estimate. It should reflect the information reasonably available when it is issued, including the planned procedure, expected codes, scheduled date, and anticipated services.

If the expected scope changes, a new estimate may be required. Centers should document the assumptions used, the source of benefit data, the date eligibility was checked, and the reason for any later revision.

Required Information in the Patient Estimate

• Patient name
• Date of birth
• A description of the primary item or service in clear and understandable language
• Scheduled date of service, if applicable
• Items and services reasonably expected to be furnished during the period of care
• Applicable diagnosis codes and expected service codes, such as CPT, HCPCS, DRG, or NDC codes when relevant
• Expected charges associated with the listed items or services
• Provider or facility name, National Provider Identifier, and Tax Identification Number
• Location where services are expected to be provided
• Required disclaimers, including that actual charges may differ and that eligible patients may use the patient-provider dispute resolution process

Consent

For certain out-of-network cases, a provider may be permitted to ask a patient to waive federal balance billing protections through the standard notice and consent process.

This is a limited exception, not a general authorization to balance bill every out-of-network patient. The provider or facility must follow CMS requirements and any more protective state law.

The law prohibits balance billing for certain services provided by an out-of-network provider at an in-network facility unless the notice and consent exception is legally available and every requirement is met.

Providers and facilities must use the federal standard documents, or an approved state form that meets federal requirements, and provide a plain-language explanation that signing means the patient is giving up protections and may pay more than the in-network cost-sharing amount.

The patient’s decision must be voluntary. A signature that merely acknowledges receipt of a disclosure is not the same as written consent to waive protections.

When the exception is allowed, the notice must include a good faith estimate of the out-of-network charges and must be completed within the federal timing rules.

The notice and consent exception is not available for many ancillary services, including certain:

• Anesthesiology services
• Pathology services
• Radiology services
• Laboratory services
• Neonatology services
• Assistant surgeon services
• Hospitalist services
• Intensivist services

It also cannot be used for unforeseen urgent medical needs that arise during care. An ASC should confirm that a service is legally eligible before asking a patient to waive protections.

Provider Directories

You must accurately disclose which plans you participate with and assist your payors with maintaining accurate provider directories.

Providers and facilities that have or had a network agreement must submit directory information:

• At the beginning of the agreement
• When the agreement terminates
• When material information changes
• When the plan or issuer requests verification

The No Surprises Act directory requirements also place obligations on plans and issuers. They must maintain current public directories, verify and update directory information at least every 90 days, establish a process to remove providers they cannot verify, and update their database within two business days after receiving directory changes from a provider or facility.

If a plan gives a patient inaccurate information stating that a provider is in network, the patient may be protected from paying more than the in-network cost-sharing amount. 

Insurance ID Card Requirements

The No Surprises Act ID card requirements apply directly to health plans and issuers. Still, providers should understand them because front-office staff rely on the card during registration and verification.

Physical and electronic identification cards must include, in clear writing:

• Applicable deductibles
• Applicable out-of-pocket maximum limitations
• A telephone number and website address for consumer assistance

Pending more detailed rulemaking, plans and issuers may use a reasonable method, including a QR code or digital link, for additional benefit information. 

Dispute Resolution

Two different dispute processes are important, and they should not be confused.

The patient-provider dispute resolution process is available to an uninsured or self-pay individual when a billed charge from a provider or facility is at least $400 more than the expected charge shown on the Good Faith Estimate.

The patient generally must begin that process within 120 calendar days after receiving the initial bill.

The Federal Independent Dispute Resolution process, by contrast, is generally used by providers, facilities, air ambulance providers, plans, and issuers to resolve certain out-of-network payment disputes. The patient is not a party to the Federal IDR case.

A strong prevention strategy is better than a dispute strategy. Accurate estimates, clear scope descriptions, verified network information, documented patient communications, clean claims, and timely payer follow-up all create a stronger record if a disagreement occurs.

Following dependable ASC billing guidelines and workflows can also reduce preventable claim errors and reimbursement delays.

These practices reduce the chance that a patient is placed in the middle of a payment issue that should be resolved between organizations.

Our Recommendations

Many of the No Surprises Act requirements reflect sound business practices, including accurate insurance verification, early estimates, plain-language communication, current directory information, and documented consent.

The statute contemplates cost information for insured patients through an Advanced Explanation of Benefits process, but that process has not yet been fully implemented.

Centers should prepare flexible data and communication workflows without telling patients that a federal insured-patient Good Faith Estimate or Advanced Explanation of Benefits process is already operational when it is not.

Here is our recommended action plan for creating and maintaining a practical No Surprises Act compliance program.

Assign Accountable Owners

Designate an executive sponsor and operational owners for registration, estimates, contracting, billing, compliance, website content, and dispute management.

Create a Requirements Matrix

List each federal and state requirement, the affected patient population, the responsible department, the required timing, the record that proves completion, and the escalation path.

Build a Network Participation Source of Truth

Reconcile payer contracts, product participation, facility locations, physicians, anesthesia providers, laboratories, and other ancillary providers.

Maintaining strong data integrity across clinical and financial systems can help staff work from consistent and reliable information throughout the patient journey.

Standardize Insurance Verification

Confirm coverage, plan product, network status, effective dates, deductible, out-of-pocket maximum, coinsurance, prior authorization, and known carve-outs.

Separate the Documents

Make sure staff understand the difference among:

• The general disclosure notice
• A Good Faith Estimate
• A patient financial policy
• An authorization
• The notice and consent form used to waive certain protections

Test the Timing Rules

Audit whether disclosures, estimates, and notice and consent documents are delivered within the correct federal or state timeframe.

Train Staff With Real Scenarios

Include emergency versus scheduled care, insured versus self-pay status, out-of-network providers, late case additions, revised procedures, patient questions, and complaints.

Retain Evidence

Store the estimate, source data, delivery date, disclosure, consent documents, website version, payer communications, and any revised information in a retrievable format.

Review processes whenever regulations or payer practices change.

The Bottom Line for ASCs

The No Surprises Act is no longer a new law waiting for a January 2022 start date. Its central balance billing protections, disclosures, uninsured and self-pay Good Faith Estimates, directory protections, and dispute processes are part of the current operating environment.

At the same time, several provisions still depend on future rulemaking or good-faith implementation, including parts of the insured-patient estimate and Advanced Explanation of Benefits framework.

Successful compliance requires more than downloading a form. It requires:

• Accurate data
• Clear ownership
• Current payer participation information
• Disciplined timing
• Accessible patient communication
• Reliable record retention
• Regular review

When those practices are built into scheduling and revenue cycle workflows, the result is not only better compliance. It is greater billing transparency in healthcare, fewer patient surprises, more productive staff, and a stronger financial experience for both the patient and the ASC.

Connecting estimates with an efficient patient payment solution can also give patients a more convenient way to review and pay their expected financial responsibility.

An integrated ASC software platform can help centers connect financial clearance, patient communication, scheduling, billing, payments, and reporting through more consistent workflows.

Book a demo to see how HST’s patient estimates can help your surgery center streamline cost estimates, support consistent workflows, and give patients clearer financial information before their procedure, helping your team reduce surprises and build greater trust.