Skip to main content

No Surprises Act Working as Intended, But Gaps Remain Leaving Patients Vulnerable

Analysis  |  By Jay Asser  
   April 28, 2023

Emergency ground ambulance services are one of the blind spots of the regulation that could be improved with federal intervention.

The No Surprises Act (NSA) is protecting patients from most surprise bills as intended, but the law's scope fails to protect certain vulnerable pockets, according to new analysis by the Urban Institute and Georgetown University's Center on Health Insurance Reforms, with funding from the Robert Wood Johnson Foundation.

Researchers conducted 32 interviews with federal and state regulators, as well as organizations representing a spectrum of stakeholders like consumers, employers, payors, physicians, hospitals, air ambulance providers, and medical billing companies.

Informants largely agreed that one year after the NSA went into effect, patients are being "well protected" from surprise bills. In one state, for example, insurance regulators said that of the 1,800 insurance-related consumer complaints received in 2022, only two were NSA-related.

Another state regulator was a "little surprise" by the lack of complaints, but "attributes this to insurers' and providers' cooperative efforts to eliminate balance bills and correct them when they occur."

The analysis also found that patients appear to be protected from services that previously left them exposed to surprise billing, like air ambulance services. Additionally, researchers said the NSA is "getting consumers 'out of the middle' of payment disputes between providers and payors.

However, gaps remains in the law for other services like ground ambulance, which one state regulator noted can result in patients being billed nine out of 10 times.

"Although the limited evidence to date suggests that consumers are being well protected from balance billing in the situations covered by the NSA, some stakeholders remain concerned that gaps in the law can leave consumers with unexpected financial liability," the report stated.

"The failure to include emergency ground ambulance services, in particular, means that many patients will continue to be balance billed for out-of-network services they had no choice but to accept."

Though researchers say it's too early to determine whether the NSA will "constrain the growth in health insurance premiums and encourage broader provider networks," policymakers need to track provider and insurer compliance for potential billing patterns to address vulnerable areas.

In a survey by Morning Consult, 20% of respondents said they or their family had received a surprise bill in 2022, with another one in five billed after being treated by an out-of-network provider at an in-network facility.

Separate data by AHIP and the Blue Cross Blue Shield Association revealed that while the NSA averted over nine million surprise bills in the first nine months of being a law, it also led to providers submitting over 275,000 arbitration claims—nearly 10 times more than originally anticipated.

Jay Asser is the contributing editor for strategy at HealthLeaders. 


Research by the Urban Institute and Georgetown University's Center on Health Insurance Reforms found the No Surprises Act is doing well to protect patients from surprise bills.

The law still doesn't protect everyone, however, with something like ground ambulance resulting in patients being billing for out-of-network emergency services.

More needs to be done by policymakers to account for patient vulnerabilities and unexpected charges.

Get the latest on healthcare leadership in your inbox.