The No Surprises Act took effect in January 2022 to bipartisan applause. Patients, the story went, would no longer receive crushing out-of-network bills after emergency room visits or surgeries. Four years in, the picture is messier. The law fixed some scenarios cleanly, missed others entirely, and created a dispute resolution process that’s now buckling under volume. Patients are still getting surprise bills — they just look slightly different.
If you’ve assumed the problem was solved, your next ER visit may correct that impression.
What the law actually covers
The No Surprises Act prohibits balance billing for emergency services, non-emergency services at in-network facilities (when the patient didn’t have a meaningful choice), and air ambulance services. In those scenarios, the patient owes only their in-network cost share, and disputes between providers and insurers go to an independent dispute resolution process.
That’s a real improvement, and it’s eliminated certain catastrophic bills — the $40,000 anesthesiologist invoice after an in-network surgery, the out-of-network ER physician at an in-network hospital. Patients should know these protections exist and dispute bills that violate them. Many states have parallel laws that go further.
The loopholes that remain
Ground ambulance services are excluded from the law. This is the single largest remaining surprise-billing category, and it’s not an oversight — ambulance lobbies fought the inclusion. A patient calls 911, gets transported by an out-of-network ground ambulance, and receives a bill of $1,500 to $5,000 with no protection. About a quarter of ground ambulance trips generate out-of-network charges, and patients have essentially no recourse.
Urgent care centers, which exist in a regulatory gray zone, also frequently fall outside protections. So do certain post-discharge services, durable medical equipment vendors, and labs that process specimens taken in network. Patients who think their entire encounter was in-network often discover months later that one component routed to an out-of-network entity that’s not covered by the law.
The dispute resolution problem
The arbitration process the law created is overwhelmed. The Centers for Medicare and Medicaid Services initially projected about 17,000 disputes per year. Actual volume has run ten times that. Backlogs stretch beyond a year, providers and insurers both complain about the process, and recent court decisions have repeatedly remanded the rules — most notably in Texas Medical Association cases that struck down portions of the implementation.
The practical consequence is that even disputes the law was supposed to handle are taking far longer than expected, and providers — particularly emergency physicians and radiologists — are reporting cash flow strain that’s affecting staffing in some markets. The law’s economic effects are still working their way through the system, and they’re not all flowing to patient benefit.
The takeaway
The No Surprises Act helped. It didn’t end surprise billing. Ground ambulances, urgent care, and certain ancillary services remain wide open. Patients should always ask about ambulance coverage before non-emergency transport, request itemized bills after every encounter, and dispute charges that fall under the law’s protections. Assuming the problem was legislated away is exactly how the remaining loopholes keep generating five-figure invoices for unsuspecting patients.
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