What Is the No Surprises Act?
The No Surprises Act was enacted to protect patients from unexpected medical bills — particularly in situations where they received care from out-of-network providers without their knowledge or consent. The law applies to most types of health insurance plans and covers a wide range of clinical scenarios where patients may not have had a meaningful choice of provider.
Under the NSA, patients enrolled in group health plans or individual market plans cannot be billed more than their in-network cost-sharing amounts in the following situations: emergency services at any facility regardless of network status, non-emergency services at in-network facilities from out-of-network providers, and air ambulance services from out-of-network providers. What this means in practice is that if you are an out-of-network provider treating patients in any of these scenarios, you cannot send the patient a balance bill for the difference between your charge and the insurer’s payment. Instead, any dispute about reimbursement must go directly between you and the payer — never to the patient.
The Independent Dispute Resolution Process
One of the most important mechanisms created by the No Surprises Act is the Independent Dispute Resolution process — a federal arbitration system that allows providers and insurers to resolve payment disputes without involving the patient.
When a payer’s payment falls below what you believe is appropriate, you have 30 business days after receiving the initial payment explanation to initiate open negotiation with the payer. If open negotiation fails after 30 business days, either party can initiate the federal IDR process. A certified IDR entity — a neutral third party — will review both offers and select one as the appropriate payment amount. The IDR entity considers the Qualifying Payment Amount, which is typically the insurer’s median contracted rate, along with other factors including your training, experience, market share, and the complexity of the service provided.
The critical insight here: the IDR process is genuinely winnable — and practices with strong documentation, expert billing support, and a clear understanding of how to present their case consistently recover more than payers initially offer. This is exactly why having a specialized out-of-network billing partner is not a luxury — it’s a revenue strategy.
Good Faith Estimate Requirements
One of the most operationally demanding aspects of the No Surprises Act is the Good Faith Estimate requirement. Under the law, uninsured and self-pay patients must receive a Good Faith Estimate before scheduled services — and since 2022, this requirement has expanded.
As of 2025, practices must provide a Good Faith Estimate that includes a clear itemized list of expected services and items, expected charges for each service and item, any co-providers expected to participate in the patient’s care, and the anticipated timeframe for services.
Failure to provide accurate estimates on time can result in patient complaints, regulatory review, and financial penalties. If a patient’s final bill exceeds the Good Faith Estimate by more than $400, they have the right to dispute the bill through the Patient-Provider Dispute Resolution process — which adds significant administrative burden and potential revenue risk to your practice.
What Has Changed in 2026
The regulatory landscape around the No Surprises Act has evolved significantly since its initial implementation. In 2026, providers need to be aware of several important developments.
Court decisions have continued to shape how the Qualifying Payment Amount is calculated and weighted in IDR decisions — with ongoing litigation affecting how arbitrators weigh payer-submitted rates against provider evidence. The Centers for Medicare & Medicaid Services has released updated guidance clarifying which ancillary services are covered under the facility-based protections, expanding the scope of providers affected by the law. Enforcement of Good Faith Estimate requirements has also increased, with CMS actively monitoring compliance and responding to patient complaints more aggressively than in prior years.
For out-of-network providers, this evolving landscape means that what was compliant in 2022 may not be sufficient in 2025. Regular compliance reviews, updated billing workflows, and ongoing staff training are no longer optional — they are essential practice management requirements.
Common Compliance Mistakes That Cost Providers
In working with out-of-network practices across the country, the same compliance mistakes consistently drive revenue loss and regulatory risk. The most costly include failing to provide Good Faith Estimates to self-pay patients before services are rendered, missing the 30-business-day open negotiation window before IDR eligibility lapses, incorrectly calculating the patient’s cost-sharing based on in-network rates, sending balance bills to patients in protected scenarios — a direct violation of the law — and failing to document the basis for charges submitted in IDR proceedings.
Each of these errors has a direct financial consequence — either through lost reimbursement, regulatory penalties, or both. The good news is that every one of these mistakes is preventable with the right billing infrastructure and expert support.
How to Protect Your Practice
Protecting your practice from No Surprises Act risk in 2026 requires a proactive, systematic approach. At a minimum, your practice should be implementing real-time eligibility verification at every patient encounter to identify protected scenarios before services are rendered, maintaining a compliant Good Faith Estimate workflow for every self-pay and uninsured patient, tracking all out-of-network claim payments against the Qualifying Payment Amount to identify underpayments that warrant IDR, building a documentation library that supports your charges in IDR proceedings, and staying current with CMS regulatory guidance as it evolves throughout the year.
If your current billing team doesn’t have dedicated out-of-network billing expertise, the complexity of the No Surprises Act alone is sufficient reason to partner with a specialist. The IDR process, Good Faith Estimate requirements, and balance billing restrictions require a level of regulatory knowledge and process discipline that goes far beyond standard medical billing competence.
The Bottom Line
The No Surprises Act is not going away — and in 2026, it’s more enforceable, more expansive, and more consequential than ever. For out-of-network providers, the path forward is clear: get compliant, stay current, and make sure you have the billing expertise to navigate the IDR process effectively when payers underpay. At Wave Medical Billing, our out-of-network billing specialists know the No Surprises Act inside and out — and we help practices like yours stay compliant while maximizing every dollar of out-of-network reimbursement.
Ready to make sure your out-of-network billing is fully compliant and fully optimized? Get your free out-of-network billing audit from Wave Medical Billing today.
