No Surprises Act (NSA)
A federal law effective January 1, 2022 that prohibits surprise billing for most emergency services and out-of-network services provided at in-network facilities, and creates Good Faith Estimate and dispute resolution protections.
No Surprises Act (NSA) is a term from U.S. hospital cost and quality reporting — the field that produces the CMS Hospital Compare program, the Medicare Inpatient Payment files, and the patient-facing tools built on top of them. The definition below covers what the term means in CMS files, what it does not mean, and how it interacts with the other measures CMS publishes. On the LakeQuality value rubric, No Surprises Act (NSA) is one of the inputs (directly or indirectly) to the combined cost-and-quality grade. Understanding how the term is computed at CMS — what counts and what does not — is part of reading hospital pages defensibly.
Each hospital page on LakeQuality surfaces the specific No Surprises Act (NSA) value for that facility (when CMS reports one), so the general definition here translates into a concrete data point on the per-hospital pages you actually use.
How It Works
The No Surprises Act (NSA) was enacted as part of the Consolidated Appropriations Act of 2021 with bipartisan support and took effect January 1, 2022. It represents the most significant federal hospital billing reform since EMTALA. The NSA creates five major protections. First, it prohibits balance billing for emergency services at any facility, requiring patients to pay only in-network cost-sharing regardless of the provider or facility's network status. Second, it prohibits balance billing for non-emergency services at in-network facilities when performed by out-of-network providers (anesthesiologists, radiologists, pathologists, emergency physicians, assistant surgeons, hospitalists) whom the patient did not reasonably choose. Third, it prohibits balance billing by air ambulance providers (but not ground ambulance, a major gap). Fourth, it requires providers and facilities to issue Good Faith Estimates (GFEs) to uninsured and self-pay patients before scheduled services, with a $400 variance threshold triggering patient-provider dispute resolution rights. Fifth, it creates the Independent Dispute Resolution (IDR) process for provider-insurer payment disputes using baseball-style arbitration with the Qualifying Payment Amount (median contracted rate) as the benchmark. The NSA also bans gag clauses in provider contracts that had prevented employers and regulators from seeing negotiated rates. Implementation has been contentious. The Texas Medical Association pursued multiple lawsuits against HHS/Treasury/Labor over IDR rules, winning key decisions that overturned the initial QPA-weighting presumption. IDR volume far exceeded projections: CMS estimated 17,000 disputes for the first year and received over 290,000 in 2022, 650,000+ in 2023, and continued elevated volumes in 2024-2025. Studies from Peterson-KFF and Georgetown's Center on Health Insurance Reforms have found the NSA successfully reduced out-of-network billing in affected scenarios by over 80%, but premium effects have been mixed and ground ambulance balance billing remains largely unaddressed.
Related Terms
- Surprise Medical Bill (Balance Billing), An unexpected bill from an out-of-network provider for the difference between the provider's charge and the insurance payment, largely prohibited for most scenarios since the No Surprises Act took effect January 1, 2022.
- Balance Billing, The practice of a provider billing a patient for the difference between the provider's charge and what the insurer paid, now largely prohibited in emergency and many in-network-facility scenarios under the No Surprises Act.
- Independent Dispute Resolution (IDR), The baseball-style arbitration process created by the No Surprises Act that resolves payment disputes between out-of-network providers and insurers without involving the patient.
- Good Faith Estimate, A written estimate of expected charges for scheduled healthcare services that uninsured or self-pay patients have the right to receive under the No Surprises Act, effective January 1, 2022.
- EMTALA (Emergency Medical Treatment and Labor Act), A 1986 federal law requiring Medicare-participating hospitals with emergency departments to provide screening and stabilizing treatment to all patients regardless of ability to pay or insurance status.
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About This Definition
This definition is part of the HospitalCostData Hospital Pricing Glossary, 47 terms explaining hospital costs, quality ratings, and healthcare billing. Written for patients, journalists, researchers, and healthcare professionals.