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Got an Out-of-Network Bill? Here Are Your Rights and How to Fight It

A surprise out-of-network bill can be terrifying. The good news: since January 2022, the No Surprises Act makes most of these bills illegal. This guide covers exactly what the law protects, where the gaps are, how to spot illegal balance bills, and what to do step by step.

•22 min read

Looking for general bill reduction strategies? This guide focuses specifically on out-of-network billing issues and your legal protections. For broader tactics like itemized bill review, error checking, and financial assistance programs, see our complete guide to lowering medical bills.

$750+
avg. surprise out-of-network ER bill
~1 in 5
ER visits involve an out-of-network provider
Jan 2022
No Surprises Act took effect
~35 states
have their own balance billing laws

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1

The No Surprises Act: What It Actually Covers

The No Surprises Act (NSA), effective January 1, 2022, is the most significant federal protection against out-of-network billing in U.S. history. But it does not cover everything. Understanding exactly what is and is not protected will determine your entire strategy for fighting a bill.

What the No Surprises Act DOES cover

All emergency services, regardless of network status

If you go to any emergency room (in-network or out-of-network), every service you receive is protected until you are stabilized. This includes the ER physician, any specialists called in (surgeons, cardiologists, neurologists), lab work, imaging, and all care through stabilization. You can only be charged your plan’s in-network cost-sharing amount (deductible, copay, or coinsurance). The provider must accept your in-network rate as payment in full. For more on fighting ER bills specifically, see our guide to lowering ER bills.

Non-emergency services by out-of-network providers at in-network facilities

This is the scenario that catches most patients off guard. You schedule surgery at an in-network hospital, but the anesthesiologist, radiologist, pathologist, assistant surgeon, or hospitalist assigned to your case turns out to be out-of-network. Under the NSA, these ancillary providers cannot balance bill you. You owe only your in-network cost-sharing. This specifically covers: anesthesiology, radiology, pathology, neonatology, diagnostic services (including labs and imaging), and assistant surgeons. Anesthesiologists are the single most common source of these surprise bills. See our guide to lowering anesthesia bills for detailed strategies.

Air ambulance services

Out-of-network air ambulance providers cannot balance bill you. Given that the average air ambulance bill exceeds $36,000 (and some top $100,000), this protection is enormous. You owe only your in-network cost-sharing amount.

What the No Surprises Act does NOT cover

Ground ambulances

The single biggest gap. Ground ambulance services are explicitly excluded from the NSA. About 70% of ground ambulance rides involve out-of-network billing, with average surprise bills between $450 and $1,200. Only about 14 states have their own ground ambulance protections. (More on this in the ground ambulance section below.)

Post-stabilization care if you consent to transfer/continued care

After you are stabilized in the ER, the hospital may ask if you consent to continued treatment at that out-of-network facility rather than being transferred to an in-network one. If you consent and the consent meets legal requirements, subsequent care may not be protected. However, if you are unable to consent or no in-network facility is reasonably available, protections continue.

Scheduled care at out-of-network facilities you knowingly chose

If you deliberately chose an out-of-network hospital or clinic for non-emergency care and there was no deceptive billing, the NSA generally does not apply. However, your state law may still offer protections, and you can negotiate the bill directly or request a network adequacy gap exception from your insurer.

Key numbers to know

  • The average surprise out-of-network ER bill before the NSA was $750 to $2,600
  • About 18% of ER visits and 16% of in-network hospital stays involved at least one out-of-network charge before the law
  • Anesthesiologists were the most common out-of-network surprise bill, followed by radiologists and pathologists
  • CMS has recovered over $4 million in restitution through the No Surprises complaint process as of mid-2024
  • Over 16,000 No Surprises Act complaints have been filed with CMS
3

The Independent Dispute Resolution (IDR) Process

When a provider and insurer disagree on payment for an out-of-network service covered by the No Surprises Act, the IDR process resolves the dispute. As a patient, the most important thing to know is that you are removed from the middle. Your financial responsibility is limited to your in-network cost-sharing amount no matter what the arbitrator decides.

How IDR works

1

Open negotiation (30 business days)

After the insurer sends an initial payment or denial, the provider and insurer have 30 business days to negotiate directly. Many disputes are resolved at this stage without further escalation.

2

IDR initiation

If negotiation fails, either party can initiate IDR within 4 business days. Both sides submit their final payment offer to a certified IDR entity (a neutral arbitrator).

3

Baseball-style arbitration

The arbitrator must pick one side’s offer or the other. They cannot split the difference or choose a middle amount. This structure incentivizes both sides to submit reasonable offers rather than extreme ones.

4

Decision (within 30 business days)

The arbitrator issues a binding decision. The losing party pays the IDR entity’s fee, typically $200 to $700 per dispute.

What the arbitrator considers

  • The Qualifying Payment Amount (QPA): the median in-network rate for the service in the geographic area. This is the primary factor the arbitrator must weigh.
  • Complexity of the case and the provider’s training or experience level
  • Market share of the provider or insurer in the area
  • Teaching status of the hospital
  • Demonstrations of good faith (or lack thereof) during the 30-day negotiation period

IDR outcomes: what the data shows

According to CMS data through 2024, providers win approximately 70-77% of IDR disputes. That means the arbitrator selects the provider’s higher payment offer in most cases. This matters for the healthcare system, but it does not affect you as a patient. Your maximum responsibility is always your in-network cost-sharing amount, regardless of whether the provider or insurer wins the IDR dispute. The IDR process happens between the provider and insurer only.

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4

State Balance Billing Protections

Many states enacted their own balance billing laws before the federal No Surprises Act, and some of these state laws are significantly stronger. The federal law sets a floor, not a ceiling. If your state law provides greater protection, it applies instead.

States with notable protections

New York (since 2015)

One of the first and strongest state laws. Covers all provider types and includes an independent dispute resolution process. Patients pay only in-network cost-sharing for emergency and surprise out-of-network services. Model for the federal law.

California (AB 72)

Prohibits balance billing for non-emergency services at in-network facilities. Uses an independent dispute process between providers and insurers. Patients pay only in-network rates. Covers most HMO and PPO plans regulated by the state. Also protects ground ambulance patients.

Texas (SB 1264)

Effective since 2020. Protects patients from balance billing for emergency and out-of-network services at in-network facilities. Uses the median in-network rate as the benchmark for payment disputes. Also covers emergency ground ambulance. Applies to state-regulated plans.

Florida, Colorado, Georgia, Illinois

All have comprehensive balance billing protections for emergency and certain non-emergency situations. Colorado notably requires reimbursement of out-of-network ground ambulances at 325% of Medicare, one of the strongest ambulance protections in the country. Specific details vary.

Why state law matters even after the federal law

  • Some state laws cover ground ambulances, which the federal law does not
  • Some state laws protect a broader range of services or provider types
  • State enforcement can be faster and more aggressive than federal enforcement
  • Some states provide stronger penalties and a private right of action for patients to sue
  • About 35 states now have some form of balance billing protection on the books

Important limitation: state law vs. ERISA plans

State balance billing laws generally apply only to fully-insured plans (plans where your employer buys coverage from an insurance company). They typically do not apply to self-funded ERISA plans (where your employer pays claims directly). This is one reason the federal No Surprises Act was so important: it covers both plan types. See the self-funded vs. fully-insured section below for more details.

5

How to Spot an Illegal Balance Bill

Not every out-of-network bill is illegal, but many are. Here is how to determine whether the No Surprises Act or your state law should protect you.

Your bill is likely illegal if any of these apply

You received emergency care at any facility

All emergency services are protected, regardless of network status. If the ER, an ER doctor, or any specialist consulted during your emergency sends a balance bill beyond your in-network cost-sharing, it violates federal law.

An out-of-network provider treated you at an in-network facility without valid advance consent

If you did not sign a valid consent waiver meeting all the legal requirements (72-hour notice, good-faith estimate, in-network alternatives listed, specific provider named), the provider cannot balance bill you. See the consent waiver section above.

You are being billed more than your in-network cost-sharing for a covered service

Check your Explanation of Benefits (EOB). If it shows an in-network cost-sharing amount but the provider is billing you a higher amount, this is balance billing. The provider should only collect the “Patient Responsibility” amount shown on your EOB for protected services.

An ancillary provider you did not choose is billing you separately

Anesthesiologists, radiologists, pathologists, neonatologists, assistant surgeons, and diagnostic labs at in-network facilities cannot balance bill you, period. These providers are never eligible for consent waivers under the NSA.

Quick check: compare your bill to your EOB

Your insurer is required to process protected out-of-network services at in-network rates. Pull up your Explanation of Benefits (EOB) for the service in question. Find the “Patient Responsibility” line. If the provider’s bill exceeds that number, you may have an illegal balance bill. Save both documents as evidence when you file a complaint.

6

Step-by-Step: What to Do When You Get an Out-of-Network Bill

A

Check if the No Surprises Act applies

Ask yourself: Was this emergency care? Was the provider out-of-network at an in-network facility? Was it an air ambulance? If you answer yes to any of these, the NSA likely protects you and you should owe only your in-network cost-sharing (deductible, copay, or coinsurance). If your situation does not fall under the NSA, check your state’s balance billing law next.

B

Request your Explanation of Benefits (EOB) and compare

Call your insurer or log into your online portal and pull up the EOB for the service. It should show the claim processed at in-network rates for protected services. Compare the “Patient Responsibility” amount on the EOB to what the provider is billing you. Any amount above the EOB figure for a protected service is potentially illegal balance billing.

C

Contest any consent waiver you signed

If the provider claims you waived your rights, request a copy of the signed waiver. Review it against the legal requirements in the consent waiver section above. If any element is missing (72-hour notice, good-faith estimate, in-network alternatives, voluntary consent statement, specific provider named), inform the provider in writing that the waiver is invalid under 45 CFR 149.420 and request reprocessing.

D

Request the Qualifying Payment Amount (QPA) from your insurer

The QPA is the median in-network rate your insurer pays for the specific service in your geographic area. You have the right to request this figure. It serves as the benchmark for what you should owe and what the IDR arbitrator weighs most heavily. Having this number gives you concrete leverage in any dispute with the provider.

E

File a complaint with CMS and/or your state

If the provider refuses to correct the bill, escalate immediately. You have two paths, and you can (and should) use both:

Federal (CMS)

Call 1-800-985-3059 (Mon-Fri, 8am-8pm ET) or file online at cms.gov/nosurprises. CMS has recovered over $4 million in restitution for patients as of mid-2024.

State

File with your state insurance department and/or state attorney general. State enforcement is often faster and may carry stronger penalties, including fines against the provider.

F

If you already paid, demand a refund

If you paid an illegally balance-billed amount (either to avoid collections or because you did not know your rights at the time), you are entitled to a refund. Send a written demand to the provider. Cite the No Surprises Act or your state balance billing law by name. Include copies of the bill, your EOB showing the correct patient responsibility, and proof of payment. Set a 30-day deadline for the refund. If the provider does not respond, file a complaint with CMS and your state attorney general. You may also have grounds for a small claims court action (most states allow claims of $5,000 to $10,000).

Self-Funded vs. Fully-Insured Plans

Your plan type determines which laws protect you and where you file complaints. The good news is that the No Surprises Act covers both types. But there are important differences in appeal rights and state law applicability.

Fully-insured plans

  • Regulated by your state insurance department
  • Protected by both federal (NSA) and state balance billing laws
  • File complaints with your state insurance commissioner
  • Common for small employers and individual marketplace plans
  • Broader remedies available (state bad faith laws, punitive damages in some states)

Self-funded (ERISA) plans

  • Protected by the federal No Surprises Act
  • Generally NOT subject to state insurance laws due to ERISA preemption
  • Some plans have additional arbitration clauses in plan documents
  • File federal complaints with CMS and the Department of Labor
  • ERISA provides specific appeal rights (180 days for internal appeal, then external review or federal court)
  • Common for large employers (500+ employees)

How to determine your plan type

  • Check your Summary Plan Description (SPD), which your HR department or plan administrator can provide
  • If your plan says “self-funded” or “self-insured,” it is almost certainly an ERISA plan
  • Government employee plans, church plans, and individual marketplace plans are generally NOT ERISA plans
  • When in doubt, call your plan administrator and ask directly

The key takeaway: The No Surprises Act protects both fully-insured and self-funded plans from balance billing. Your out-of-network protections apply regardless of plan type. The difference is mainly in where you file complaints and what additional state protections may be available. For more on appeal procedures if your insurer denied the claim, see our insurance denial appeal guide.

The Ground Ambulance Gap

Ground ambulance billing is the biggest hole in federal surprise billing protections. Congress explicitly excluded ground ambulances from the No Surprises Act, leaving millions of patients exposed every year.

The numbers

~70%
of ground ambulance rides involve out-of-network billing
$450-$1,200
average surprise ground ambulance bill
~14 states
have ground ambulance balance billing protections

What you can do about a ground ambulance bill

  • Check your state law first. About 14 states (including Texas, Colorado, California, Maryland, and Illinois) have their own ground ambulance balance billing protections. Colorado requires reimbursement at 325% of Medicare, one of the strongest in the country.
  • Request an itemized bill. Ground ambulance charges are notoriously error-prone. Look for duplicate mileage charges, incorrect service levels (ALS billed when BLS was provided), and add-on charges for routine supplies that should be included in the base rate.
  • Negotiate directly. Many ambulance providers, especially municipal services, will accept a reduced payment or set up a zero-interest payment plan. Ask about financial hardship programs.
  • Ask your insurer for a network gap exception. If no in-network ambulance was available (and you did not choose the ambulance company), your insurer may agree to process the claim at in-network rates. This is especially effective if the ambulance was dispatched by 911.
  • Federal action is pending. Congress established a Ground Ambulance and Patient Billing Advisory Committee to study this issue. The committee has made recommendations, but legislation has not yet been enacted as of May 2026.

Dealing with a complex out-of-network situation?

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Frequently Asked Questions

Does the No Surprises Act cover emergency room visits?

Yes. All emergency services are protected regardless of whether the facility or any individual provider is in-network. This includes the ER physician, any specialists consulted during the emergency, lab work, imaging, and all care until you are stabilized. You can only be charged your plan’s in-network cost-sharing amount (deductible, copay, or coinsurance).

Can a doctor ask me to waive my No Surprises Act protections?

Only in very limited circumstances. For non-emergency, scheduled services at an in-network facility where the specific provider is out-of-network, the provider can request a waiver. But it must include 72-hour advance written notice, a good-faith cost estimate, a list of in-network alternatives, and a clear statement that consent is voluntary. Emergency services and ancillary providers (anesthesiologists, radiologists, pathologists) can never be waived. You can always refuse and request an in-network provider.

What is balance billing and is it legal?

Balance billing is when an out-of-network provider bills you for the difference between their charge and what your insurance paid. Under the No Surprises Act, balance billing is illegal for emergency services at any facility, for non-emergency services from out-of-network providers at in-network facilities (like anesthesiologists and radiologists), and for air ambulance services. For scheduled non-emergency care at an out-of-network facility you deliberately chose, balance billing may still be legal unless your state has additional protections.

What should I do if I get a surprise bill from an anesthesiologist?

If your procedure was at an in-network facility, the anesthesiologist cannot balance bill you under the No Surprises Act, even if they were personally out-of-network. Compare the bill to your EOB. If the bill exceeds your in-network cost-sharing amount, call the billing department and cite the No Surprises Act. If they refuse to adjust, file a complaint with CMS at 1-800-985-3059. For more detail, see our guide to lowering anesthesia bills.

Does the No Surprises Act cover ground ambulance bills?

No. Ground ambulance is the most significant gap in the federal law. About 70% of ground ambulance rides involve out-of-network billing, with average surprise bills of $450 to $1,200. Approximately 14 states have their own ground ambulance balance billing protections. A federal advisory committee has made recommendations to Congress, but legislation has not yet been enacted.

What is the IDR (Independent Dispute Resolution) process?

IDR is the federal arbitration system for resolving payment disputes between providers and insurers under the No Surprises Act. After a 30-business-day negotiation period, either party can initiate IDR. A neutral arbitrator selects one party’s final offer (baseball-style arbitration). Providers win approximately 70-77% of IDR cases. The critical point: your out-of-pocket responsibility is limited to your in-network cost-sharing amount regardless of the IDR outcome. The dispute is between the provider and insurer only.

Does the No Surprises Act apply to my employer health plan?

Yes. The No Surprises Act covers both fully-insured plans and self-funded employer plans governed by ERISA. This was one of the law’s most important provisions, because self-funded ERISA plans were previously exempt from most state balance billing protections. Some self-funded plans may have additional arbitration clauses in plan documents, and ERISA-governed plans have different appeal procedures if a claim is denied.

How do I file a No Surprises Act complaint?

Call the No Surprises Help Desk at 1-800-985-3059 (Monday through Friday, 8am to 8pm ET) or file online at cms.gov/nosurprises. You will need your medical bill, your Explanation of Benefits, and any consent forms you were asked to sign. CMS will acknowledge your complaint and follow up within 60 days if additional information is needed. You should also file with your state insurance department for additional enforcement leverage.

What if I already paid the balance bill? Can I get a refund?

Yes. Paying a bill does not waive your rights under the No Surprises Act. Send a written demand for a refund to the provider, citing the specific law they violated. Include copies of your bill, EOB, and proof of payment. Set a 30-day deadline. If the provider does not comply, file a complaint with CMS and your state attorney general. You may also be able to pursue recovery through small claims court.

Related Resources

How to Negotiate and Lower Your Medical Bills

General strategies for reducing medical bills through itemized review, error checking, financial assistance, and direct negotiation.

Read guide

How to Appeal a Health Insurance Denial

If your insurer denied the out-of-network claim entirely, use our step-by-step appeal guide with template letters and strategies.

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How to Lower Your ER Bill

Specific tactics for reducing emergency room charges, the most common source of out-of-network surprise bills.

Read guide

How to Lower Your Anesthesia Bill

Anesthesiologists are the most common source of out-of-network surprise bills at in-network facilities.

Read guide

How to Lower Your Surgery Bill

Surgical billing often involves multiple out-of-network providers. Learn how to identify and dispute each charge.

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This guide is for informational purposes only and does not constitute legal or medical advice. Balance billing laws and protections vary by state, plan type, and individual situation. Consult with a licensed professional for advice specific to your circumstances. Statistics cited are based on publicly available data from CMS, the Kaiser Family Foundation, the Commonwealth Fund, and state insurance department reports, and may vary.