When Brittany Cloyd, a Kentucky teacher, went to an in-network emergency room in 2021 for complications during pregnancy, she was treated by an out-of-network physician she never chose. The bill ran into the thousands. “I did everything right,” Cloyd told lawmakers during congressional testimony that helped build the case for federal action. “I went to an in-network hospital, and I still got a surprise bill.”
Since January 1, 2022, a federal law has been on the books to stop exactly that. The No Surprises Act prohibits out-of-network emergency providers and facilities from billing patients more than what they would owe under in-network cost-sharing. Your copay, coinsurance, or deductible stays the same whether the ER doctor happens to be in your network or not. The provider and your insurer are supposed to sort out the rest between themselves.
More than four years later, patients across the country are still receiving surprise bills that violate the law. Many pay without questioning the charge, unaware that federal law is on their side.
What the law actually says
The statutory language is unusually direct. Section 300gg-131 of Title 42 of the U.S. Code bars out-of-network emergency facilities and clinicians from charging patients more than the in-network cost-sharing amount. The ban covers both the hospital’s facility fee and the individual physician’s bill, closing a loophole that previously left patients exposed even when they had no say in which doctor treated them.
The protections also extend to out-of-network air ambulance services. Ground ambulances, however, are not covered, a gap discussed further below.
Under the law, health plans must calculate what a patient would have owed in-network and reflect those amounts on explanation-of-benefits (EOB) statements. If the system works as designed, a patient should never see a surprise balance bill for emergency care.
How state laws can strengthen your protection
The No Surprises Act sets a federal floor, but it does not preempt stronger state protections. Before the federal law existed, roughly 33 states had already enacted their own surprise billing statutes, according to tracking by the Commonwealth Fund. Many of those laws remain in effect. States such as New York, California, Texas, Colorado, and Florida have balance-billing protections that in some cases cover services the federal law does not, including ground ambulance rides or non-emergency out-of-network care at in-network facilities.
Which law applies to you depends on how your health plan is regulated. Plans purchased on the individual market or through small employers are typically state-regulated. Most large-employer plans fall under the federal ERISA framework, which state laws generally cannot reach. If you are covered by a large employer, the federal No Surprises Act is likely your only protection. If your plan is state-regulated, you benefit from whichever law is stronger. Your state insurance department can tell you which rules apply to your specific plan.
Why illegal bills keep showing up
The No Surprises Act created an independent dispute resolution (IDR) process so that providers and insurers could fight over reimbursement rates without dragging patients into the middle. That system has been troubled almost from the start.
The U.S. Government Accountability Office examined the IDR process in report GAO-24-106335, covering April 2022 through June 2023. The GAO documented significant backlogs, system outages, and shifting regulatory guidance that left both providers and insurers uncertain about how disputes would be resolved. The agency described the rollout as “challenging.”
Legal battles have compounded the dysfunction. The Texas Medical Association and other provider groups have filed multiple lawsuits against the Department of Health and Human Services over how the IDR process weighs insurers’ median in-network rates. Federal courts have struck down portions of the implementing rules more than once, forcing HHS to revise its approach repeatedly. Each round of litigation has introduced fresh uncertainty and further slowed the resolution pipeline.
Jack Hoadley, a research professor emeritus at Georgetown University’s Health Policy Institute who has studied the law’s rollout, has described the dispute resolution system as being “in turmoil” since its launch. That turmoil has real consequences for patients.
Consider what that turmoil looks like from a patient’s perspective. You go to the ER, you get treated, and weeks later a bill arrives for thousands of dollars from a doctor you never selected. You have no idea that a federal law prohibits that charge. You pay it because the envelope says “past due” and you do not want your credit damaged. Multiply that scenario across millions of ER visits each year, and the scale of wrongful payments becomes staggering even without precise federal data to quantify it.
When providers and insurers cannot settle their disputes efficiently, the financial confusion spills over onto the people the law was supposed to protect. Some providers continue sending balance bills because of administrative error, outdated billing systems, or deliberate pressure to collect. Some insurers fail to process claims correctly at the outset, meaning the improper charge reaches the patient before anyone flags it. Either way, patients end up paying bills they do not legally owe.
How much money is at stake
As of mid-2026, no one knows the full scale. CMS publishes quarterly IDR Public Use Files, but no publicly available federal dataset breaks down the share of emergency-specific disputes, tracks the dollar amounts patients wrongly paid before filing complaints, or reports how often those payments are ultimately refunded.
The GAO’s review covered a window that ended in June 2023. No comparable independent federal audit covering the period since has been published in publicly available records, which means the best government oversight data on the IDR system reflects conditions that are now roughly three years old.
CMS does maintain a federal complaint portal where patients can report suspected violations, but raw complaint volume has not been released in a form that isolates ER-specific cases. Without that data, policymakers and consumer advocates are left estimating the problem’s size rather than measuring it.
What patients should actually do
If you receive a large bill after an emergency room visit from an out-of-network provider, do not assume the charge is valid just because it arrived in the mail. Here is a concrete path forward:
1. Pull your explanation of benefits. Your insurer is required to send you an EOB for the visit. Compare the amount the plan says you owe (your in-network copay, coinsurance, or deductible) to what the provider is billing you. If the provider’s bill exceeds the EOB amount, that difference is an illegal balance bill under the No Surprises Act.
2. Check whether you received a notice of your rights. Under the No Surprises Act, providers must give patients a notice explaining their balance-billing protections. If you never received one, that itself is a violation worth reporting.
3. Call your insurer first. Sometimes the problem is a processing error on the plan’s side. Ask your insurer to confirm whether the claim was processed under the No Surprises Act’s emergency protections. If it was not, ask them to reprocess it.
4. Contact your state insurance department. If your plan is state-regulated, your state has its own complaint process and balance-billing protections that go beyond the federal law. Many state departments maintain consumer hotlines and can intervene directly with insurers or providers.
5. File a federal complaint. If the bill persists, use the CMS No Surprises Help Desk complaint portal to report it. You can upload copies of the bill, your EOB, and any correspondence. CMS states that complaints may trigger investigations or corrective action against the provider or insurer. You can also call 1-800-985-3059 for assistance.
6. Do not pay under pressure. If a provider sends the disputed bill to collections, you have the right to dispute the debt and cite the No Surprises Act. It is also worth knowing that as of 2023, the three major credit bureaus (Equifax, Experian, and TransUnion) removed paid medical debts from credit reports and raised the threshold for reporting unpaid medical debt to $500, which gives patients more room to dispute without immediate credit damage.
7. If you already paid, request a refund. Patients who paid a surprise balance bill that violated the law can file a complaint through the same CMS portal and request that the provider refund the overpayment. There is no publicly stated federal deadline for requesting a refund, but acting quickly strengthens your case. Keep copies of every bill, EOB, and payment receipt.
Gaps that still leave patients exposed
Even with federal and state protections in place, several holes remain.
Ground ambulances. The No Surprises Act does not cover ground ambulance services, leaving patients vulnerable to surprise bills that can run into the thousands for a single ride. A federal advisory committee has studied the issue and delivered recommendations, but as of mid-2026, Congress has not extended the ban. Some states, including New York and Colorado, have enacted their own ground ambulance billing protections, but coverage varies widely by state.
Post-stabilization care. Once a patient is stabilized in the ER, an out-of-network facility can, under certain conditions, ask the patient to consent to continued out-of-network treatment. If the patient agrees, or is presented with paperwork they do not fully understand, the balance-billing protections no longer apply for subsequent services. Patient advocates have raised concerns that consent obtained in a hospital bed, sometimes while a patient is still groggy or in pain, does not meet any reasonable standard of informed consent.
Enforcement gaps. The enforcement infrastructure itself remains a work in progress. Without ER-specific complaint data, dispute outcome tracking, or regular independent audits of the IDR system, there is no reliable way to measure whether compliance is improving or deteriorating.
The law is clear, even when the billing system is not
The No Surprises Act did something rare in American health policy: it gave patients an unambiguous legal right not to be balance-billed for emergency care. That right does not depend on which hospital the ambulance takes you to, which doctor walks into the room, or whether your insurer and provider can agree on a price. It is written into federal statute, reinforced by dozens of state laws, and it applies right now.
The problem is not the law. The problem is that the machinery behind it (the billing systems, the dispute resolution process, the enforcement pipeline) has not caught up. Until it does, patients who know their rights and are willing to push back are the ones most likely to keep the money that is already, by law, theirs.
Warren Cohen is a finance writer based in Phoenix, Arizona, covering personal finance topics including credit, banking, and beginner investing. He earned his degree in business administration from Arizona State University and began his career working in consumer finance, where he gained direct experience with lending and credit systems. He now writes for personal finance websites and fintech platforms, focusing on clear, practical content that helps readers make informed financial decisions.
