Protecting Patients — and Your Practice — Under the No Surprises Act (NSA)
For specialties like anesthesia, radiology, pathology, and emergency medicine, out-of-network (OON) billing is a daily reality. The No Surprises Act (NSA) changed how those claims are handled — protecting patients from unexpected bills while creating a structured process for providers and payors to resolve payment disputes.
If you’re an OON provider, understanding what patients owe, what you can collect, and how the Independent Dispute Resolution (IDR) process works is essential for maintaining compliance and maximizing recovery.
What Patients Pay — and What They Don’t
When an out-of-network provider delivers services covered by the NSA — such as anesthesia during an in-network surgery or emergency care — patients are protected from balance billing.
- Patients are only responsible for their in-network cost-sharing amount (copay, coinsurance, or deductible).
- The amount is based on the Qualifying Payment Amount (QPA) — the plan’s median in-network rate for the same service.
- Providers may not bill or collect any amount beyond that in-network share.
For example:
If the in-network coinsurance is 20% and the plan’s QPA for an anesthesia service is $400, the patient pays only $80 — even if the provider’s billed charge is $1,200.
When the Provider Wins Through IDR
If the payor’s initial payment is inadequate and the provider prevails in IDR arbitration, the plan must pay the full award amount within 30 days. Importantly, the patient owes nothing additional — all remaining payment is settled directly between the plan and provider.
The provider’s accounts receivable may rise temporarily due to the dispute cycle, but the net revenue recovery increases significantly when IDR awards are managed effectively.
What Out-of-Network Providers Must Do: Patient Disclosures and Forms
Even though patients can’t be balance-billed for NSA-protected services, compliance still requires proactive disclosure.
Here’s what OON providers must ensure:
- Provide the Mandatory Patient Disclosure Notice
- All out-of-network providers and facilities must give patients a “Notice of Patient Protections Against Surprise Billing.”
- This disclosure informs patients that they cannot be billed beyond their in-network share for emergency and certain ancillary services.
- A standard notice form can be downloaded from CMS
- Post the Disclosure Publicly
- The notice must be posted prominently on your website and in any physical location where patients receive care.
- It should also be provided to patients directly (electronically or in print) prior to or at the time of service when possible.
- Secure Signed Consent When Balance Billing Is Permitted
- For certain non-emergency, non-ancillary services, OON providers may use the “Notice and Consent Form” to inform patients of their OON status and obtain agreement to potential balance billing.
- This form must include:
- A good-faith estimate of costs,
- Clear identification of the OON provider, and
- Confirmation that in-network alternatives were offered if available.
- CMS template available here:
CMS Model Notice and Consent Form (PDF)
Compliance and Revenue Can Co-Exist
Many providers assume NSA compliance means lost revenue — but that’s not the case. By using IDR effectively, out-of-network specialists can protect patients and still recover fair market reimbursement.
- Patients pay only their in-network share.
- The balance is settled between provider and plan via IDR.
- With proper documentation, timely filing, and accurate disclosure, compliance strengthens your position in arbitration and minimizes audit risk.
Take Control of Your OON Revenue
At BillWell, we help providers like yours navigate NSA compliance while maximizing recovery through IDR. From patient disclosures to arbitration submissions, our process is transparent, compliant, and performance-based.
See how your OON claims could perform in IDR — request a complimentary revenue assessment today.
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