The No Surprises Act took effect on January 1, 2022, and it affects physician practices in two main ways. You have to give uninsured and self-pay patients a good faith estimate before scheduled care. And in situations the law covers, you can’t bill patients more than in-network cost-sharing. Most practices handle the first part loosely and don’t realize the second part applies to them at all.
What Does the No Surprises Act Require From Physician Practices?
For an independent practice, the law comes down to three obligations:
- Good faith estimates (GFEs) for uninsured and self-pay patients, on a fixed timeline.
- Balance billing limits on emergency services and on care from out-of-network providers at in-network facilities.
- Notice and consent rules for the narrow cases where an out-of-network provider at an in-network facility may still balance bill.
If your practice only sees patients in its own office and is in-network with most of its payers, the GFE rules are the part you deal with every week.
When Is a Good Faith Estimate Due?
CMS guidance sets the timeline by how far ahead the service is scheduled:
- Scheduled at least 3 business days out: the GFE is due no later than 1 business day after scheduling.
- Scheduled at least 10 business days out: the GFE is due no later than 3 business days after scheduling.
- Patient asks for cost information: the GFE is due no later than 3 business days after the request.
The GFE has to list the items and services you reasonably expect to provide, the diagnosis and service codes, expected charges for each, and a notice explaining the patient’s dispute rights. Patients in federal health care programs such as Medicare and Medicaid don’t qualify for the uninsured/self-pay GFE.
What Is the $400 Dispute Threshold?
An uninsured or self-pay patient can start the patient-provider dispute resolution process if the final bill is at least $400 more than the total expected charges for that provider on the GFE. The patient has 120 calendar days from receiving the initial bill to file.
So the GFE isn’t just paperwork. It sets the number your final bill gets measured against. Practices that send a generic estimate and then bill add-on services they didn’t list are the ones that end up in disputes.
Where Do Balance Billing Limits Apply?
For emergency services, and for non-emergency care from out-of-network providers at in-network facilities, the patient owes no more than in-network cost-sharing. The out-of-network provider and the plan settle payment between themselves, through open negotiation and, if that fails, the federal independent dispute resolution (IDR) process.
Some out-of-network providers at in-network facilities can use notice and consent to balance bill. The AMA’s summary of the law describes written notice and consent given 72 hours before the appointment. Notice and consent is not available for radiology, pathology, emergency medicine, anesthesiology, diagnostic and neonatal services, assistant surgeons, hospitalists, intensivists, or when no in-network provider is available.
A Practical No Surprises Act Checklist
- Ask about coverage at scheduling, and flag every uninsured or self-pay patient for a GFE.
- Use a GFE template that pulls real CPT and ICD-10 codes and your actual charge for each, not a ballpark total.
- Track the 1- and 3-business-day deadlines in your scheduling system, not in someone’s head.
- Compare the final bill to the GFE before sending it. If the gap is close to $400, find out why.
- Post the required disclosure notice about balance billing protections, and keep it current.
- Know whether you work at in-network facilities where you are out-of-network, and whether your specialty can use notice and consent at all.
- Keep the GFE with the patient record so you can produce it if a dispute is filed.
The co-provider piece has moved around. CMS guidance said that starting in 2023, GFEs would include estimates from co-providers and co-facilities, but HHS has used enforcement discretion on that requirement until further rulemaking. Check the current HHS guidance before building it into your workflow.
The No Surprises Act also sits on top of your existing billing compliance obligations, and it works best when your eligibility verification catches self-pay status before the visit rather than after.
Frequently Asked Questions About the No Surprises Act
Does the No Surprises Act apply to small physician practices?
Yes. The good faith estimate requirement applies to any provider that schedules care for uninsured or self-pay patients. The balance billing limits apply when the practice provides emergency services or works out-of-network at an in-network facility.
What happens if the final bill is higher than the good faith estimate?
If the bill is at least $400 more than the expected charges for that provider on the GFE, an uninsured or self-pay patient can start the patient-provider dispute resolution process within 120 calendar days of receiving the initial bill.
Do Medicare patients get a good faith estimate?
No. Patients enrolled in federal health care programs such as Medicare and Medicaid are not eligible for the uninsured/self-pay good faith estimate.
What are the penalties for violating the No Surprises Act?
The AMA’s summary of the law says HHS may impose civil monetary penalties of up to $10,000, with possible waivers when the provider did not knowingly violate the law and corrects the problem.
What OmniBridge Actually Does
We build the GFE step into front-desk intake, using real codes and real charges, and we check final bills against the estimate before they go out. That keeps self-pay patients from getting a bill that triggers a dispute.
If you aren’t sure your current estimates would hold up in a dispute, request a free practice audit and we’ll review a sample with you.
