17 Hidden Gotchas in the New No Surprises Act Final Rule

Added: 2026-06-03

[00:00:00]There are a shocking amount of surprises in the new final rule for the so-called no surprises act that's supposed to help people save money on their medical bills and improve transparency and all this stuff. Kind of cracks me up that the final rule is 600 and something pages when the goal is to increase transparency, but that's a whole different conversation, I suppose.

[00:00:20]Today, we're going to be talking about what I found in that document and the 17 or so gotchas that you really need to be aware of because maybe you were like me.

[00:00:29]When I first heard about the No Surprises Act, I was super excited because it was supposed to reduce surprise bills, improve price transparency at hospitals and other providers, and just generally help you not get screwed by the health care system. That's what it was supposed to do. Anyway, there's a new final rule that's been released that kind of reveals a lot of hidden loopholes that I didn't know existed, and I don't want you to get blindsided by any of this either. So today we're going to break down what I found in that document, who might be affected, what you need to watch out for, and all those things that you need to know. Now, let's start with a quick refresher of what the No Surprises Act even is, because you may not know it by its name, but hopefully you've seen the positive impacts of it over the last couple of years. So, this was first passed in 2020. It went into effect January of 2022 and it was considered at the time a landmark effort to shield patients from unexpected medical bills. I don't know about you, I have experienced these unexpected bills in the past and I was really excited at the idea that that era might be over because basically there were a couple of key protections in here. The big thing was that it was supposed to shield you from surprise charges for out of network care. Whether that was at an emergency room or because one of the providers at the hospital was out of network. For example, if you had a surgery and the anesthesiologist wasn't in network, then you got a bigger surprise bill, right?

[00:01:58]It was supposed to kind of curb all of that. It also required providers to give you a good faith estimate upfront so that you could actually price compare services, which is huge. and it established what was supposed to be a fair dispute process for insurers and providers. I don't know if you've ever had the unpleasant experience of having to go between your provider and your insurance company and back and forth to try to get a bill paid, but I have lost hours and hours and hours of my life being the middleman. So, I was really excited, especially for that provision.

[00:02:31]And that one seems to be the main target of this new 600 and something page rule that we went over today. But before we dive into all of the loopholes and gotchas that are in that rule, I do want to highlight one thing that is getting a lot of positive attention, and that is the fact that the new final rule does slash the fee by about 85%.

[00:02:53]Previously, it was $115 to file a medical billing dispute. Now, it's just $15 to file that dispute. A lot of people are saying this is good progress.

[00:03:01]I'm going to show you in a few minutes here why I don't think that's the case.

[00:03:05]But since this was build as a good news item, I figured I'd give it to you here up front. Now, let's dive into the things that are actually going to affect you. First one, and this is a big one, ground ambulances are still not protected. The law specifically protects you from surprise bills for air ambulances, but it specifically excludes ground ambulances from that coverage. So even in an emergency where you have zero choice of who shows up, you could still receive a huge out of network bill for a ground ambulance ride. And this is a big deal because this gap affects millions of people. Ambulance bills can be crazy expensive. Now, another problem, perhaps one of the biggest problems, is that corporate providers have really figured out how to rig this system in their favor, which I guess shouldn't be surprising because they kind of do that with everything. But basically, consumer advocates like Families USA have warned that private equitybacked medical companies are are learning how to flood this dispute system, basically creating massive numbers of claims to get higher payments than they would have if they went through normal negotiations. And that is something we've already seen in action. So when they first set up this no surprises act and this fair dispute resolution process, the government estimated that they'd see maybe like 17,000 disputes a year, right? They weren't expecting that many. Instead, in reality, what they've experienced is over 5 million disputes being filed in the last four years. That's over a million disputes a year. They were off by a very significant margin. And a lot of that comes down to this corporate flooding that's going on. And that is why Families USA says that dropping this fee is actually a bad choice because it's going to make it even easier for corporatebacked providers to just flood that resolution process and increase the number of disputes they think by as much as 30%. Which when you're talking about millions, a 30% uptick is very significant. And more disputes means more delays for everyone else. But we are not done. There is still so much more here you need to know. Because another trap in here is that they don't even have to tell you why they're disputing anything. Right? Originally, the government proposed forcing the party initiating the dispute to provide a written statement explaining exactly why they're taking the issue to arbitration and why they couldn't reach a deal during the open negotiation phase. And they completely backed down on that. They deleted the requirement entirely, meaning that those big corporate companies and insurers can just initiate hundreds of disputes without ever having to tell you why they're disputing. They're just disputing and they're probably hoping they're going to get more money from it, but they don't have to give you any sort of answer. They don't have to have any accountability there. And that is really, really frustrating. Now, the next trap just builds on that, and that is that there's no good faith standard for negotiations, right? So the rules say that both parties have to have an open negotiation period before they can file a dispute, but nobody knows exactly what that means or what that's supposed to look like. So a lot of people asked the regulators to create some sort of requirement for meaningful participation or penalty for companies that just don't engage with that arbitration. And they said no. The government said that the law does not specify how those parties have to negotiate and that if they had any of those rules, it would just be a chilling effect on the whole process, which seems really frustrating because basically they're saying those companies can stonewall the negotiations. And along with that, there are also no penalties for insurance companies that break the rules, it looks like. So, from what I read, it looks like advocates were begging the government to add strict financial penalties for insurers that don't follow those billing transparency requirements. And instead, they said no. They said they'd rely on existing processes. No new enforcement or anything like that was added. There's also no penalties for flooding the system with ineligible claims. So, they're really not discouraging these companies from filing these millions and millions and millions of claims. In fact, they're making it really easy for them to do this. They're saying that a big reason there is this huge millions of claim backlog is because a lot of people are submitting claims that aren't eligible for the process. And so they originally proposed a system that would charge different fees based on who was at fault or that there would be some sort of penalty in there. And they eventually scrapped that. So now it's a flat $15 fee, meaning there is no financial penalty to deter people who are lazily flooding the system with junk claims. In fact, they made the fee cheaper, so it's easier for those people to do that. And I think that is really really frustrating. Now on top of all of this, so they've made it really really easy, right, for the corporations to file a whole bunch of disputes and there's really not a lot of accountability built in here. But then also they decided that your insurance card doesn't have to tell you your rights under any of this. So they had considered requiring insurers to print some surprise billing rights on your insurance ID card so that you would know what to do if something went wrong. And in the final rule, they decided not to require that at all. So, you're on your own to figure out whether you have that state or federal protection applied to your plan, which I think is really unfair. Right? If there is something you can do or someone you can call, that information should be widely available to you. We are going to talk a little bit later about what you can do if you think you're affected by this. But you shouldn't have to rely on YouTubers and random people who research this stuff for fun to get you that information. It should be transparent and available to you. That was the entire point of the No Surprises Act was to make all of this stuff more transparent and easy to use.

[00:08:54]So, this one right here, so frustrating.

[00:08:57]Also, another trap, there's no price caps and no fixed rates. So, advocates said that the best protection would be setting a clear benchmark rate, right?

[00:09:05]Like a standard fair price based on what in network providers normally get paid.

[00:09:10]And this rule does not do that either.

[00:09:12]Instead, disputes are still settled through arbitration, which can result in higher payouts for providers who are really insistent. Now, with all of this, of course, one of the great downsides is your health insurance premiums could still go up, right? Families USA is warning that all of the abuses and opportunities that are built into this system could raise health insurance costs for all consumers, including you, which, you know, is really unfair. But they're saying that when these large providers file all these disputes and win all these inflated payouts through the arbitration, those extra costs get passed along to everyone who pays health insurance premiums. So, I'm just curious. I've been hearing from a lot of people. If you've seen your health insurance premiums go up lately, I would love it if you drop a yes in the comments just so we can kind of see how you guys are being affected and also that helps our video reach more people and we always appreciate that. Now, trap number 10 is a big one and everybody needs to know this. So, please listen closely. This one is probably the most important one. Actually, there's some really important ones coming later, but this is one of the most important ones for sure. And that is that you can still be balanced build if you sign a certain form. So, your provider may not tell you this. I know whenever I go into a provider's office, they hand me a big clipboard full of papers and there's privacy policies and HIPPA notices and all of the things. And depending on what your provider hands you, if this form is in there, it could effectively wave your protection under some of these rules. So the final rule talks about something called a notice and consent exception.

[00:10:44]And what this means is that in some non-emergency situations, if an outof network provider gives you a written notice and you sign it, they can legally bypass these protections and charge you the full out of network difference. So, it is extremely important that you read carefully anything before you sign it at a medical office. Always ask if the provider is in network. Understand what you're signing and be careful in your decision to sign it. In fact, there's a notice on the Centers for Medicaid and Medicare Services website that says, "If you sign this form, be aware that you may pay more because you're giving up your legal protections from higher bills. You may owe the full cost build for the items and services you get and your health plan might not count any of the amount you pay towards your deductible and out-ofpocket limit.

[00:11:35]Contact your health plan for more information. Before deciding whether to sign this form, you can contact your health plan to find an in-et network provider or facility. If there isn't one, you can also ask your health plan if they can work out an agreement with this provider or facility or another one to lower your costs. So it is extremely important that you take this seriously.

[00:11:56]You ask those questions and you don't sign things that you don't understand just generally. That's just a good practice. And then there's this clause which is really frustrating for a lot of people on this channel and that's that the protections don't even help people who are on Medicare or Medicaid. That's because the federal dispute process is only for certain commercial insurance plans like employer or marketplace coverage. and Medicare and Medicaid have their own separate billing protections.

[00:12:23]So, they've been left out of this specific rule. Now, if you are on Medicare or Medicaid and you're receiving high or confusing medical bills, this particular rule may not help you, but there may be other protections out there that can. We do have an amazing partner over at Chapter that can help you answer all of your Medicare specific questions. you'd like us to cover a similar topic for those of you on Medicare or Medicaid as far as the nuances and things that you need to know, let us know and we will get that done for you as well. Now, just continuing on with this no surprises act, the new rules require those insurance companies to use standardized codes to explain why a claim was paid or denied, but only on paperwork to your doctor. They don't need to be sent to you as the patient. So, your explanation of benefits may be just as confusing as it was before. And of course, this final rule does nothing to fix the final the massive backlog that we have either. The new rules do allow them to group up to 50 claims together to help speed things up, but they also lowered those fees and they're expecting 30% more claims. So, that's not really going to help with the backlog issue that we're seeing here.

[00:13:33]Because of that, there is no guarantee of a fast resolution. the system is already so overwhelmed that they're trying to build these escape hatches into the rules, but there's no real timeline on when any action can be taken on this just because there's millions of claims in there. And then this one really bothers me. They do not owe you a written explanation when your dispute is thrown out. So, if your medical billing dispute is reviewed and then thrown out by an arbitrator because maybe they deemed it ineligible, the provider might want to know exactly went wrong so they can fix it in the future. And no, the government said that they are not going to require anyone to provide written rationale explaining why a dispute was found eligible or ineligible. They said that that would be too much of a burden on the already overwhelmed system, which of course just leaves patients and providers more in the dark. There also does not appear to be a formal appeals process if your dispute is wrongly rejected. It looks like if your billing dispute is thrown out by an arbitrator, even by mistake, there's not really anything you can do about it. commenters asked the government to create a process for this and they explicitly refused. So if you think a mistake was made, you're told to call the no surprises help desk and file a complaint. But again, they don't have to give you a reason why they threw it out either. So how would you file an appeal on that? I don't even know. Very, very frustrating stuff in here, guys. And a lot of small doctors are saying that they're being treated unfairly because large corporate providers can file these batch disputes.

[00:14:57]And if they file a batch dispute, they only have to wait 30 days before refiling against the same insurer.

[00:15:03]Whereas a small independent doctor filing a single claim has to wait 90 days. So those little guys have to wait three times longer than the big system.

[00:15:13]And that just seems like a serious disadvantage there. So what can you do at this point? First, you need to know your plan, right? Does it even qualify for no surprises protections? That's a good thing to find out. Next, don't sign anything without reading it first. I cannot stress that enough. It's just so important that you always understand what you're putting your name on. And then, of course, if you get a surprise bill, call the NoSurprises help desk or visit cms.gov/nosuppurprises to learn your rights and file a complaint there. I hope this has been helpful to you. I know it's been very discouraging, but between the exclusion for the ground ambulances and the carveouts for Medicaid and Medicare and, you know, the ability to sign away your protections altogether, I felt like this was information you guys really needed to know. So, thank you for watching.

[00:16:03]Please share this with others so no one else is caught off guard. And I'll be back soon with better news for you on how you can save money and make the most of your benefits. I'll see you there.