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No Surprises Act (NSA) Federal Balance Billing Defense
⚖️ Governing Authority: 42 U.S.C. § 300gg-111 & 45 CFR § 149
Effective January 1, 2022, the No Surprises Act protects patients from unexpected balance bills for emergency services and non-emergency services provided by out-of-network clinicians at in-network healthcare facilities.
Key Statutory Rules & Protections
- No balance billing for emergency room physicians, anesthesiologists, radiologists, or pathologists.
- Cost-sharing (deductibles/copays) must be calculated using the In-Network Qualifying Payment Amount (QPA).
- Notice and Consent exceptions NEVER apply to emergency medicine or ancillary diagnostic specialists.
- Providers facing non-payment must enter the 30-day Federal Independent Dispute Resolution (IDR) process rather than billing the patient.
Step-by-Step Action Plan
- Demand an itemized bill with CPT and revenue codes.
- Identify out-of-network provider NPI numbers operating within the in-network hospital.
- Submit certified NSA Dispute Challenge citing 42 U.S.C. § 300gg-111.
- File federal complaint via CMS No Surprises Help Desk (1-800-985-3059).
Need to Dispute an Aggressive Medical Bill?
Our AI automatically drafts a customized dispute demand citing 42 U.S.C. § 300gg-111 & 45 CFR § 149 ready to mail or submit online.
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