Strong rules are key to success of the No Surprises Act

 Consumer and health advocates urge final rules that offer full patient  protections

surgeon with mask in OR

With guest co-author, Quynh Chi Nguyen at Community Catalyst

In the coming weeks, the federal government will finalize the rules for the No Surprises Act which established landmark consumer protection from unfair high-cost medical bills from out-of-network providers. As of January 1, so-called surprise medical bills became illegal. Millions of people who are privately insured no longer have to worry about receiving an unexpected bill for hundreds or thousands of dollars from a health care provider who was involved in their treatment, but out of their insurance plan’s network. In fact, according to a recent survey, in the first two months of 2022, there were over 600,000 bills that triggered the patient protections. That’s a tremendous result for those patients who otherwise would have faced an expensive medical bill. The No Surprises Act also aimed to help drive down overall costs for all insured people. It established an arbitration system to settle payment disputes between these out-of-network providers and insurance companies, so providers can’t simply charge whatever they want.

But some providers who have been profiting from the surprise billing practice aren’t happy with losing their money-making scheme. They’ve responded by filing numerous lawsuits  against both the law itself and the interim final rules defining the arbitration system.  

Facing strong pressure from these providers to weaken the law and the arbitration rules,  Community Catalyst and U.S.PIRG reached out to the Biden Administration sending a letter urging them to stand firm on the three key principles set out by Congress in the No Surprises Act:

  1. Protecting patients from surprise medical bills;

  2. Ensuring patients understand their rights under the No Surprise Act; and

  3. Steering clear of implementing any approach that accelerates the rise of health care costs.

Our letter encourages the Tri-Agencies (the U.S. Department of Health and Human Services, the U.S. Department of Labor, and the U.S. Department of Treasury) responsible for implementing the law to issue a final rule which is consistent with President Biden’s critical goals of making health care more affordable and accessible for everyone. 

To address rapidly rising health care costs, the No Surprises Act and the Interim Final Rules establish necessary guardrails for arbiters to use when deciding out-of-network reimbursement rates for surprise billing cases. The law and the rules point to the “qualifying payment amount” (essentially, the median in-network rate paid for the same procedure in that local region) as the central factor to be considered. Unfortunately, the district court decision rendered in the case filed by the Texas Medical Association removed these guardrails. The impact of this decision is that some providers will have a green light to routinely use the arbitration system knowing they are more likely to win oversized payments. Our letter pointed out: “Without the guardrails pointing to the primacy of the Qualifying Payment Amount (QPA) in payment decisions in the interim final rules, some providers will try to obtain higher, inflated rates, leading to increased health care costs and higher premiums for consumers.” We call on the Biden Administration to uphold their commitment to hold down health care costs so everyone can have a peace of mind when accessing the care they need.

Our letter also calls on the Tri-Agencies to deploy effective approaches to inform all patients regardless of their health insurance status about their rights under the No Surprises Act. We recommended improvements to the various required patient notices to ensure that hospitals screen uninsured and underinsured patients for hospital financial assistance or other public health insurance programs to help reduce their medical bills and protect them from aggressive collection practices.

Consumers fought hard to win the billing protections under the No Surprises Act. Our letter stressed the importance of putting patient and consumer needs first as the Biden Administration takes this last step to finalize the implementing rules. 

Photo by @nci by Unsplash


Patricia Kelmar

Senior Director, Health Care Campaigns, PIRG

Patricia directs the health care campaign work for U.S. PIRG and provides support to our state offices for state-based health initiatives. Her prior roles include senior policy advisor at NJ Health Care Quality Institute, associate state director at AARP New Jersey and consumer advocate at NJPIRG. She was appointed to the Ground Ambulance and Patient Billing Advisory Committee in 2022 and works with patient advocates across the U.S. Patricia enjoys walking along the Potomac River and sharing her love of books with friends and family around the world.