This article is co-authored by partner Virginia (Gia) Grimm and JGL law clerk Samantha Gordon.
An emergency room bill with unanticipated expenses can be a burden. Congress recognized this and enacted a statute in 2022 called the No Surprises Act. This statute protects patients from surprise medical bills received from out-of-network providers.
How Does the No Surprises Act Work?
Before the 2022 No Surprises Act, out-of-network providers could bill patients the difference between the charges billed and the amount paid by insurance – a concept called balance billing. These types of bills are commonly referred to as “surprise bills.”
Under the No Surprises Act, providers are not permitted to send patients surprise bills, in most circumstances, but must instead bill the insurer. Within 30 days of receiving the bill, the insurer must either submit payment or notify the provider that it will not pay for the service. This means that the insurer has the responsibility of responding to the provider’s bill, not the patient.
If the insurer and provider cannot reach an agreement about payment, the provider is permitted to initiate Independent Dispute Resolution (IDR), a third-party resolution process established in The No Surprises Act. In IDR, an independent certified third party hears the positions of both the insurer and provider. The third party then decides how much money, if any, the insurer owes the provider. The third party’s decision is binding in most circumstances.
Does the No Surprise Act Apply to Me?
The No Surprises Act applies to most emergency services, many non-emergency services, and air ambulance services.
The No Surprises Act applies if you have coverage through an employer or union, the Federal Employee Health Benefits Program, a Health Insurance Marketplace, or an individual plan purchased from an insurance company.
The No Surprises Act does not apply to you if you receive coverage through Medicare, Medicaid, Children’s Health Insurance Program, Indian Health Service, Veterans Affairs Health Care or Tri Care. However, you may receive other related protections through these programs. The No Surprises Act also does not apply to short-term insurance plans or limited-benefit plans (such as dental only plans).
September 2026 Case Highlighting Inability for Providers to Enforce Payment under No Surprises Act
While the No Surprises Act was intended to protect patients, it raises a potentially unintended consequence for providers. A recent Second Circuit case interpreted the No Surprises Act, determining that the statute does not allow providers to enforce payment they are owed. See E.Coast Advanced Plastic Surgery v. CIGNA, No. 25-2204, 2026 U.S. App. LEXIS 28449, at *17-18. This case involved an out of network provider, East Coast Advanced Plastic Surgery (“ECAPS”), and Cigna, an insurance company. ECAPS billed patients’ services to Cigna, who refused to pay for the services patients received. See id. at *7. ECPAS then initiated IDR and the certified third party determined that Cigna owed ECAPS 3 million dollars. See id.
Despite this decision, Cigna refused to pay. See id. Even though ECAPS did not receive the payment it was owed, the court found that ECAPS was not permitted to bring action against Cigna due to how The No Surprises Act was written. See id. at *17-18. The court reasoned that the statute only expressly permits the government to enforce payments and fails to expressly extend this right to providers, so the legislators intended to exclude providers from bringing such actions. See id.
While this case only applies to a certain area of the United States, the concept of being prevented from bringing an action is still important to recognize.
Implications of No Surprise Act and ECAPS v Cigna
The No Surprises Act is a piece of legislation that can greatly protect your rights as a patient. If you are billed directly for a service that is out-of-network and that is covered by the statute, it is great to know that you should not be billed directly for this service. Further, it is important to recognize that, as demonstrated by ECAPS v. Cigna, The No Surprises Act may have unintended consequences for providers attempting to collect owed monies.
