You chose an in-network hospital. You verified your surgeon was in-network. Then a bill arrived from an anesthesiologist or radiologist you’ve never heard of — someone you never consented to hire — billing you out-of-network rates for work done while you were under.
This is a surprise medical bill, and you may not owe it.
Since January 2022, federal law has significantly limited when providers can surprise-bill patients. Even before those protections apply, there’s a series of steps you should take before writing any check.
Here is exactly what to do when you get a surprise medical bill — including how to dispute it, cite the No Surprises Act, and escalate if the provider refuses to back down.
Step 1: Verify the Bill Is Actually Correct
Before disputing anything, confirm what you’re actually looking at.
- Request your itemized bill: A line-by-line breakdown shows exactly what was billed and by whom. The summary bill you typically receive first hides this detail.
- Pull your Explanation of Benefits (EOB): Your insurer’s EOB shows what was billed, what they paid, and what they say you owe. The EOB and the provider’s bill should tell the same story — if they don’t, there’s an error.
- Check the network status of every provider: Your insurer’s online directory or member services line can confirm whether each billing provider was in-network at the time of service.
If the bill has errors (wrong amounts, out-of-network coding for an in-network provider, services you didn’t receive), follow the standard billing dispute process — see our guide to disputing a medical bill.
Step 2: Determine Whether the No Surprises Act Applies
The No Surprises Act (effective January 1, 2022) prohibits certain out-of-network charges. It protects you when:
Emergency care: Any emergency service — regardless of whether the facility or providers are in your network. You can only be charged your in-network cost-sharing (deductible, copay, coinsurance).
Non-emergency care at an in-network facility: Out-of-network providers at an in-network hospital or ambulatory surgical center generally cannot bill you more than in-network rates — this covers anesthesiologists, radiologists, assistant surgeons, hospitalists, and similar providers you didn’t select.
Air ambulance: Out-of-network air ambulance companies face the same restrictions.
The law does NOT protect you if:
- You’re at an out-of-network facility by choice
- You received a valid written notice-and-consent form, understood the out-of-network implications, and signed it voluntarily (with specific timing and content requirements that many rush-intake forms don’t meet)
- Services were provided by ground ambulance
Step 3: Contact Your Insurer
Call the member services number on your insurance card and:
- Tell them you believe you received a surprise bill that may violate the No Surprises Act
- Ask them to reprocess the out-of-network claim at in-network cost-sharing rates
- Get the representative’s name, date, and reference number
- Follow up the call with a written request (certified mail) citing the No Surprises Act
Your insurer is required by law to apply in-network rates to qualifying surprise bills. If they processed the claim incorrectly, a corrected EOB should reduce or eliminate your out-of-pocket cost.
Step 4: Contact the Provider
Separately, contact the billing department of the provider who sent the unexpected bill:
- Tell them you believe the bill violates the No Surprises Act
- Ask them to reprocess the claim with your insurer as in-network
- Request that they pause collection activity while the situation is being resolved
Many providers are unaware of — or ignoring — their obligations under the No Surprises Act. A direct conversation sometimes resolves the issue before any formal complaint is needed.
Step 5: File a Complaint If Needed
If your insurer and the provider don’t resolve it:
Federal complaint (CMS): Contact the CMS No Surprises Help Desk at 1-800-985-3059 or at cms.gov/nosurprises. This is the primary enforcement agency. See our detailed guide on how to file a No Surprises Act complaint.
State insurance commissioner: For fully insured plans, your state may have additional protections. File a complaint with your state insurance commissioner at naic.org/state_contacts.
CFPB: For billing or collection complaints, the Consumer Financial Protection Bureau at consumerfinance.gov/complaint.
What If the No Surprises Act Doesn’t Apply?
If your situation falls outside the law’s protections — you’re at an out-of-network facility, or ground ambulance services — you still have options:
- Negotiate the balance: Out-of-network bills are often based on inflated chargemaster rates. Request the Medicare rate or a self-pay discount.
- Appeal your insurance denial: If your insurer denied coverage, file an internal appeal citing medical necessity and circumstances.
- Apply for financial assistance: See our guide on hospital charity care.
- Check your state’s protections: Some states have broader surprise billing laws that may cover situations federal law doesn’t.
Ready to Take Action?
Our free Dispute Letter Generator builds a customized letter citing the No Surprises Act for your specific situation. Our Complete Dispute Kit is $19 one-time. Get it →
FAQ
Q: I went to an in-network ER, but the ER doctors billed me out-of-network. Is this covered? A: Yes. The No Surprises Act explicitly covers emergency room physician groups, which are often separate companies from the hospital and frequently out of network. You can only be charged your in-network ER cost-sharing amount.
Q: My insurance company says the No Surprises Act doesn’t apply to my plan. Is that right? A: Possibly — but verify it. The Act covers most employer plans, individual/family plans, and marketplace plans. It does not cover grandfathered plans or certain limited-benefit plans. Ask your insurer to explain in writing why your plan is exempt. If you think they’re wrong, file a complaint with the CMS Help Desk.
Q: The out-of-network provider says I signed a consent form authorizing out-of-network billing. Do I have to pay? A: Only if the consent form met the strict federal requirements — including timing, content, and the specific services covered. A consent form signed at intake as part of a general packet typically doesn’t satisfy these requirements for fmergency services or for most ancillary providers (anesthesiologists, radiologists, etc.). Request a copy of the form and compare it against CMS’s consent requirements.
Q: How long does it take to resolve a surprise billing complaint? A: It varies. Some complaints are resolved directly with the provider in days. CMS investigations can take weeks to months. If collection is imminent, prioritize the direct contact with insurer and provider first, then file the formal complaint simultaneously.
Q: Can the provider send a surprise bill to collections while I’m disputing it? A: Providers should not refer a disputed account to collections while a No Surprises Act complaint is pending, but enforcement varies. If collection activity begins, send a debt validation letter to the collector and include documentation that a formal complaint is pending. See our guide on medical bills and collections.