The No Surprises Act has been in effect since January 2022, but many small and independent practices in Arizona still have questions about how it applies to them. The law limits what patients can be billed in certain out-of-network situations, requires specific disclosures before services are provided, and creates a dispute process patients can use if a bill significantly exceeds the estimate they were given. Understanding your obligations under this law is not optional: noncompliance can result in civil monetary penalties up to $10,000 per violation.
What the No Surprises Act Does
The No Surprises Act (NSA) is a federal law designed to protect patients from unexpected bills when they receive care from out-of-network providers in circumstances where they had limited ability to choose. Before the law, a patient could go to an in-network hospital, receive care from an out-of-network anesthesiologist or radiologist who worked there, and then receive a large bill from that provider with no warning. The NSA closes that gap in specific situations.
The law operates in two main areas. First, it limits what out-of-network providers can charge patients in covered situations and establishes a process for resolving payment disputes between providers and insurers. Second, it requires all providers, regardless of network status, to provide uninsured and self-pay patients with Good Faith Estimates before scheduled services.
When the NSA's Balance Billing Protections Apply
The balance billing restrictions under the NSA apply in these specific circumstances:
Emergency services
If a patient receives emergency services from an out-of-network provider or at an out-of-network emergency facility, the patient's cost-sharing (copay, deductible, coinsurance) can be no more than what they would have paid in-network. The provider cannot bill the patient for anything above that amount. This applies even if the patient receives ongoing post-stabilization care that extends beyond the immediate emergency, unless the patient is given proper notice and consents in writing to out-of-network charges, with certain exceptions for medical necessity.
Non-emergency services at in-network facilities
This is the provision most relevant to specialists and ancillary providers who work at in-network hospitals, surgery centers, or other facilities. If a patient goes to an in-network facility for a non-emergency procedure and receives services from an out-of-network provider at that facility, that out-of-network provider cannot balance bill the patient beyond in-network cost-sharing amounts. This applies to specialties including emergency medicine, anesthesiology, pathology, radiology, neonatology, and certain surgical specialties.
There is an exception: if the out-of-network provider gives proper advance notice and the patient provides written consent at least 72 hours before a scheduled service (or three hours before an unscheduled same-day service), the patient can voluntarily waive their protections. However, this exception cannot be used in emergency situations, and patients cannot be required to waive their protections as a condition of receiving care.
Air ambulance services
Out-of-network air ambulance services from providers that are enrolled in any insurance plan are subject to balance billing restrictions. This is less common for most small practices but relevant for providers who work with emergency transport.
The Good Faith Estimate Requirement
The Good Faith Estimate (GFE) requirement is the portion of the NSA most likely to affect independent practices in Tucson and Southern Arizona, because it applies to all providers regardless of whether they accept insurance, and it covers uninsured and self-pay patients specifically.
If you schedule a service for a patient who is uninsured or who indicates they will not be using their insurance for a particular service (such as a patient paying cash for a service outside their deductible), you are required to provide a written Good Faith Estimate of expected costs.
What a Good Faith Estimate must include
- Your name, NPI, and contact information
- A list of expected items and services, including CPT or HCPCS codes
- Expected charges for each item and service
- Expected diagnosis codes (ICD-10)
- A statement that the GFE is an estimate and actual charges may differ
- The expected service date
- Information about the patient's right to dispute a bill that significantly exceeds the estimate
If you are aware of other providers who will be involved in the patient's care (such as a facility, an anesthesiologist, or a lab), you are required to coordinate with them and include their expected charges in the GFE as well. This "convening provider" obligation can be administratively complex for practices that coordinate care with other providers.
When the GFE must be delivered
| Scheduling Situation | GFE Must Be Provided |
|---|---|
| Appointment scheduled 3 or more business days in advance | Within 1 business day of scheduling |
| Appointment scheduled 10 or more business days in advance | Within 3 business days of scheduling |
| Patient requests a GFE without scheduling | Within 3 business days of the request |
What happens if the final bill is significantly higher than the GFE
If a patient's final bill exceeds the Good Faith Estimate by more than $400 in the aggregate, the patient has the right to initiate a Patient-Provider Dispute Resolution (PPDR) process through the federal government. The patient submits a dispute, and an independent arbitrator reviews whether the higher charges were justified. Losing a PPDR dispute means the provider must accept the GFE amount or a lower adjusted amount as payment in full.
The $400 threshold is measured across all items and services combined, not line by line. A patient receiving multiple services with several small overages may still meet the threshold. If the scope of a patient's care changes materially from what was originally scheduled, updating the GFE before providing the additional services is the right approach, both for compliance and for maintaining patient trust.
Required Patient Notice Posting
The NSA also requires providers to post a notice informing patients of their rights under the law. This notice must be:
- Posted prominently in your office and on your website
- Available in the 15 most common languages spoken in your geographic area
- Provided to patients in writing upon request
CMS has produced a standardized notice template that providers can use. Posting this in your waiting room and adding it to your website's patient information section satisfies the requirement. For practices in Tucson and Southern Arizona, Spanish-language versions are particularly important given the region's bilingual patient population.
What the NSA Does Not Require
A few important clarifications for small practices:
- The NSA does not apply to insured patients for scheduled, in-network services. If a patient is using their insurance and is seeing an in-network provider, the GFE requirement does not apply. The patient's plan is responsible for providing cost estimates in that situation.
- The balance billing restrictions do not apply to all out-of-network situations. If a patient chooses to see an out-of-network provider at an out-of-network facility for a scheduled, non-emergency service, the balance billing restrictions generally do not apply. The patient chose to go out of network knowing the provider was not in their plan.
- Medicaid and Medicare have separate rules. The NSA applies to commercial and marketplace plans. AHCCCS (Arizona Medicaid) and Medicare have their own balance billing rules, which generally prohibit providers from billing beneficiaries beyond their cost-sharing amounts regardless of the NSA.
Frequently Asked Questions
What is the No Surprises Act?
The No Surprises Act is a federal law that took effect January 1, 2022. It protects patients from unexpected out-of-network bills in specific situations: emergency services, non-emergency services at in-network facilities from out-of-network providers, and air ambulance transport. It also requires providers to give uninsured and self-pay patients a Good Faith Estimate of costs before scheduled services.
Does the No Surprises Act apply to all providers in Arizona?
The federal No Surprises Act applies to providers who participate in federally regulated health plans, which covers most employer-sponsored and marketplace insurance plans. Providers who see only self-pay or uninsured patients are primarily affected by the Good Faith Estimate requirement. Arizona also has its own state-level surprise billing law (SOONBDR) for plans governed by state insurance law, such as some individual and small-group plans.
What is a Good Faith Estimate and when must I provide one?
A Good Faith Estimate (GFE) is a written document itemizing expected costs for a scheduled service, including provider charges and any co-provider costs you are aware of. You must provide a GFE to uninsured or self-pay patients within one business day of scheduling if the appointment is within three business days, within three business days if the appointment is within 10 days, and within three business days when a patient requests one without scheduling.
What happens if my bill exceeds the Good Faith Estimate?
If the final bill exceeds the Good Faith Estimate by more than $400 in the aggregate, the patient has the right to dispute the bill through the Patient-Provider Dispute Resolution (PPDR) process. Updating the GFE proactively when the scope of services changes is the best way to avoid disputes and maintain patient trust.
Questions About Your Billing or Revenue Cycle?
A.W. Medical Billing LLC handles clean claim submission, eligibility verification, denial management, credentialing, and revenue cycle management for small and independent practices throughout Tucson and Southern Arizona. We are AAPC-certified, locally owned since 2020, and we offer free consultations.
Call us at (520) 704-5811 or email [email protected].