Surprise Billing Model Notice
Surprise medical bills, also called balance billing, have been a major concern for employees and employers alike. The federal No Surprises Act (NSA), which took effect in 2022, created important protections for patients and requirements for health plans. These protections remain in place in 2026, and there have been updates around how the law is enforced and how disputes are resolved.
This article will walk you through what balance billing is, what the law requires, recent developments, and what employers need to know to stay compliant.
What Is Balance Billing?
When you visit a doctor or facility that is not in your health plan’s network, you may be billed for the difference between what your plan pays and what the provider charges. This is called balance billing.
Balance billing often leads to surprise medical bills when:
- You need emergency care and cannot choose who treats you.
- You visit an in-network facility but unknowingly receive care from an out-of-network provider.
These charges can be significantly higher than in-network costs and may not count toward a patient’s annual out-of-pocket maximum.
What the No Surprises Act Protects You From
Since January 1, 2022, patients are protected from balance billing in several key situations:
Emergency Services
- If you have an emergency medical condition and are treated at an out-of-network hospital or emergency department, you cannot be charged more than your in-network cost-sharing amount (copay, coinsurance, deductible).
- This protection continues after you are stabilized, unless you consent in writing to out-of-network costs.
Certain Services at In-Network Facilities
- At an in-network hospital or ambulatory surgical center, some providers may still be out-of-network (for example, anesthesiologists, radiologists, pathologists, or assistant surgeons).
- In these cases, you can only be charged your in-network cost-sharing amount.
- You are never required to waive your protections or agree to be balance billed.
Compliance Requirements for Employers and Plan Sponsors
Employers that sponsor group health plans must comply with the disclosure rules under the No Surprises Act. These include:
- Making information about surprise billing protections publicly available on a website.
- Including disclosure language on explanations of benefits (EOBs).
- Using plain language and ensuring accessibility for individuals with limited English proficiency or disabilities.
- Following federal civil rights laws requiring meaningful access and nondiscrimination.
Failure to comply can expose plan sponsors to penalties and create employee confusion.
Updates to the No Surprises Act Since 2022
While the core patient protections have not changed, there have been important updates:
Independent Dispute Resolution (IDR)
The IDR process allows providers and insurers to resolve disputes over out-of-network payment amounts. Since 2022, the process has been refined and litigated:
- More certified IDR entities have been added to handle growing demand.
- Courts, including the Fifth Circuit in 2025, have reviewed aspects of the process, leading to further regulatory guidance.
- Delays in insurers honoring IDR decisions have prompted proposed legislation to impose penalties for noncompliance.
Legislative Proposals
Lawmakers introduced the No Surprises Act Enforcement Act in 2025 to strengthen enforcement against insurers that fail to pay after IDR decisions. While not yet law, it signals increasing oversight of compliance.
Provider and Plan Behavior
Data shows some providers, including those backed by private equity, are frequently using arbitration, which may increase costs. Policymakers continue to monitor whether the Act is meeting its goal of reducing surprise bills without driving up healthcare expenses.
What Employers Should Do Now
Employers and HR leaders should take steps to remain compliant and support their employees:
- Review disclosures: Ensure the required information is posted publicly and included in EOBs.
- Update communications: Use plain language and confirm accessibility for all employees.
- Monitor compliance partners: Verify that your carrier or third-party administrator is following the latest NSA requirements.
- Stay informed: Watch for regulatory updates and potential new enforcement rules.
How Parker Insurance Helps
At Parker Insurance, we help mid-market companies simplify compliance and protect both their workforce and their bottom line. Our team stays current on regulatory changes like the No Surprises Act and provides proactive guidance so you can focus on running your business with confidence.
If you have questions about compliance or want to ensure your employee benefits program meets federal requirements, we are here to help.
