The No Surprises Act 2025 represents one of the most significant healthcare billing reforms in recent history. First enacted in 2022, the law was designed to protect patients from surprise billing, large, unexpected medical charges that arise when patients unknowingly receive care from out-of-network providers or facilities. Such bills created both financial hardship and mistrust in the healthcare system, prompting federal action.
With its 2025 update, the Act introduces stricter compliance standards (NSA compliance), stronger documentation requirements, and faster dispute resolution timelines. For providers, this means adapting revenue cycle workflows, investing in staff education, and maintaining meticulous records to ensure both compliance and patient trust. According to CMS guidance, these changes are not optional, they are now core to the way healthcare billing must operate.
What is the No Surprises Act 2025?
The No Surprises Act 2025 is a federal law created to protect patients from unexpected medical bills when they unknowingly receive care from out-of-network providers. First introduced in 2022, the Act was a response to widespread frustration with surprise billing, where patients received large, unplanned charges after emergency visits or hospital stays. The law ensures that patients only pay their standard in-network cost-sharing obligations, such as deductibles or co-pays, while disputes over the remaining payment are settled directly between providers and insurers. The Centers for Medicare & Medicaid Services describes these protections as a fundamental shift in healthcare billing practices, moving the responsibility away from patients and toward negotiated resolutions.
Protecting Patients from Out-of-Network Emergency Care
Non-Emergency Care at In-Network Facilities
Air Ambulance Services and High-Cost Transport
Another major source of unexpected charges comes from air ambulance services, which are frequently billed at out-of-network rates. The 2025 update of the Act continues to include protections in this area, recognizing that patients rarely have the ability to choose their air ambulance provider in emergencies. According to a report by the U.S. Government Accountability Office, more than two-thirds of air ambulance transports were billed out-of-network, leading to some of the highest medical bills patients face. The Act requires insurers and providers to negotiate payment amounts without passing excessive costs onto patients, thereby addressing one of the most financially devastating forms of surprise billing.
The Ban on Balance Billing
charged the difference between what their insurer reimburses and what the provider charges. This prohibition applies across the emergency and non-emergency situations described above, effectively removing patients from the middle of billing disputes. As explained by the U.S. Department of Health and Human Services, the Act establishes a direct negotiation process between payers and providers, creating fairness in how services are reimbursed.
Key Changes in the 2025 Update
More Detailed Good Faith Estimates (GFEs)
Providers must now provide itemized estimates for uninsured and self-pay patients. This includes expected costs for ancillary services (labs, anesthesia, imaging) and must be delivered within strict timelines. Failure to do so may result in penalties, as outlined by CMS Good Faith Estimate requirements.
Increased Penalties
Civil monetary penalties have increased. Providers who fail to meet deadlines, submit incomplete GFEs, or continue to engage in balance billing face significantly higher fines. The HHS Office of Inspector General (OIG) has included enforcement of surprise billing regulations in its oversight agenda.
Required Staff Training
Every team member involved in scheduling, billing, or financial communication must undergo routine training, with proof of completion available for audits. The OIG stresses that staff education is a cornerstone of long-term compliance.
Why NSA Compliance Matters for Providers
Compliance is not only about avoiding penalties, it’s about preserving patient trust and financial stability. Surprise billing has been a longstanding source of frustration for patients, and transparency in pricing is now a regulatory expectation.
For providers, NSA compliance ensures:
- Faster payments by avoiding disputes.
- Lower denial rates with accurate documentation.
- Improved patient satisfaction and trust.
- Reduced risk of audits or enforcement actions.
The Office of Inspector General (OIG) has already placed surprise billing enforcement on its work plan, making proactive compliance a critical priority for healthcare organizations.
Common Surprise Billing Scenarios
While the Act covers broad situations, certain cases remain especially vulnerable to compliance issues.
Emergency care delivered at non-network hospitals often results in unavoidable out-of-network charges, while non-emergency procedures at in-network hospitals may still involve out-of-network anesthesiologists or radiologists. Additionally, specialty surgeries with mixed provider teams increase the risk of patient confusion and billing disputes. Air ambulance billing continues to be particularly problematic, with a GAO report confirming that most services are billed out-of-network.
For providers, recognizing these scenarios in advance is essential to applying the Act consistently and avoiding compliance penalties.
Independent Dispute Resolution (IDR) in 2025
The IDR process is central to resolving disputes when providers and insurers cannot agree on payment for out-of-network services.
The process begins with a 30-day open negotiation period where both parties attempt to reach an agreement. If unsuccessful, either may initiate the IDR process via the federal portal. Each party then submits its proposed payment, along with supporting evidence such as historical contract rates, complexity of services, and local market data.
The arbitrator must select one proposal as the final resolution, what is known as “baseball-style arbitration.” This format creates strong incentives for both sides to submit reasonable, well-documented offers. According to CMS IDR portal guidance, providers who maintain meticulous documentation are best positioned for favorable outcomes.
Operational Impact on Medical Billing Workflows
The No Surprises Act 2025 is not just a patient protection law; it fundamentally reshapes how billing workflows must be managed across the revenue cycle. Every department that touches financial operations is now accountable for ensuring NSA compliance, from the moment a patient calls to schedule an appointment to the final stages of payment posting and denial resolution.
Scheduling and Eligibility Verification
The compliance process begins at the very first point of contact. Scheduling staff must verify whether the facility and providers involved are in-network for the patient’s plan. If out-of-network services are likely, the law requires clear upfront disclosure. Eligibility checks should be completed using payer-approved, secure systems that can confirm network participation in real time. Without this step, providers risk initiating care that results in violations of the Act.
Pre-Authorization and Cost Transparency
Once services are scheduled, pre-authorization teams must confirm payer requirements, especially when out-of-network providers are expected to participate. At this stage, Good Faith Estimates (GFEs) are crucial. Staff must provide patients with itemized estimates of their expected charges, ensuring transparency before treatment begins. Any omissions or vague language could result in penalties or payer disputes.
Coding, Billing, and Claims Submission
Billing and coding departments now have added responsibilities. Claims must reflect the correct network status of providers involved in the patient’s care and apply the proper cost-sharing rules. Errors here can result in denials or allegations of non-compliance. Electronic claims must be transmitted securely, consistent with CMS standards, and supported by audit-ready documentation.
Denial Management Workflows
Patient Financial Communication
Cross-Departmental Accountability
What makes the Act particularly impactful is that compliance cannot rest in one department alone. It requires collaboration across scheduling, billing, coding, compliance, and patient access teams. A breakdown in any link, whether a missing eligibility check or an incomplete GFE, creates compliance risks for the entire organization. Successful providers are those that embed NSA compliance checkpoints throughout their workflows and ensure accountability at every stage.
Avoiding Common Compliance Pitfalls
Despite clear rules, providers often fall into compliance traps. Common mistakes include incomplete GFEs, missed IDR deadlines, outdated patient consent forms, and inaccurate coding of network status.
Regular internal audits and training are essential for identifying these gaps before they escalate into federal enforcement issues. Maintaining compliance documentation also ensures readiness if the Office for Civil Rights (OCR) or OIG conducts an audit.
Regular internal audits and staff training are essential to catch these issues before they result in penalties.
Training and Education for NSA Compliance
The new rules for 2025 really highlight the importance of having a knowledgeable team. Compliance programs should now include:
- Quarterly Training Modules: These should cover the latest legal changes, documentation rules, and specific out-of-network guidelines from different insurance companies.
- Role-Specific Guidance: Tailored training sessions designed for schedulers, billers, coders, and clinical staff, based on their specific jobs.
- NSA Compliance Tracking: Keeping records that show everyone has completed their required training to prove they're following the regulations.
Continuous education ensures that compliance becomes part of daily practice rather than a reactive process by CMS Training & Resources.
Helping Patients Understand the Bills
Although the No Surprises Act 2025 is primarily about compliance, patient communication is at its heart. Providers who explain costs in clear, jargon-free language are more likely to build trust and secure timely payments.
Good Faith Estimates should be delivered in a way patients can easily understand, and billing teams should be available to answer questions or resolve disputes. The HHS Patient Bill of Rights emphasizes that financial transparency is directly tied to patient confidence in the healthcare system.
Preparing for the Future
Looking ahead, providers should anticipate that protections may be expanded to cover ground ambulance services, which are currently excluded. There is also a growing likelihood of closer alignment between the Act and federal price transparency regulations, as outlined by CMS price transparency rules.
Technology will also play a bigger role. Automated tools for cost estimation, claim tracking, and IDR preparation will become essential for maintaining efficiency and reducing compliance risk. Practices that adopt these tools early will be better positioned to navigate future regulatory shifts.
Conclusion
The No Surprises Act 2025 is reshaping the financial side of healthcare by eliminating patient exposure to surprise billing and mandating provider accountability through structured NSA compliance. For billing teams, this means embedding safeguards into every stage of the revenue cycle: network verification, accurate cost estimation, audit-ready documentation, and payer-provider arbitration readiness.
From a technical perspective, the law impacts key revenue cycle metrics such as denial rates, first-pass claim acceptance, and days in accounts receivable (AR). Providers who implement strong workflows, leverage secure technologies, and maintain staff education will not only avoid penalties but also enhance payer relations and stabilize reimbursement patterns. In today’s regulatory landscape, NSA compliance is more than an obligation, it is a strategic framework for financial and operational resilience.
