No Surprises Act: Perspectives on the Status of Consumer Protections Against Balance Billing

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One year after implementation of the No Surprises Act (NSA), the law is largely protecting consumers from the most pervasive forms of surprise billing, but remaining gaps leave some patients with unexpected financial liabilities.

The Issue

Surprise balance billing occurs when insured patients receive out-of-network care and are billed for the difference between what their insurer will cover and what the care provider seeks as full payment.

Key Findings

  • Despite multiple ongoing lawsuits related to the implementation of the NSA, consumers appear to be well-protected from the most pervasive balance billing practices, such as billing for air ambulance services, that previously left them with unexpected medical bills.
  • Close monitoring of the NSA is needed, with concerns about consumer awareness of the NSA’s provisions.
  • Opportunities to expand the scope of the law’s consumer protections remain. Notably, the failure to include emergency ground ambulance services in provider networks means many people will continue to be billed for out-of-network services incurred in an emergency.
  • Researchers say it’s too early to assess whether the NSA will encourage broader provider networks or constrain growth in health insurance premiums.


Researchers indicate the No Surprises Act is protecting patients from costly payment disputes. However, gaps in the law leave some people vulnerable to continued surprise bills—often after an emergency—and further consumer protections are required to protect consumers from unexpected charges.

About the Author/Grantee

The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For nearly five decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector. Visit the Urban Institute’s Health Policy Center for more information specific to its staff and its recent research.

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