The No Surprises Act Is Finally Getting Teeth

The No Surprises Act was supposed to be a big deal when it went into effect in January 2022. And in some ways it was. It ended the most egregious forms of surprise billing, where you could go to an in-network hospital, get treated by an out-of-network doctor you never chose, and then get hit with a bill for tens of thousands of dollars.

But in the three years since, the enforcement has been... let's call it underwhelming. The independent dispute resolution process has been overwhelmed with cases, many of the protections have been difficult for patients to actually invoke, and plenty of providers have found creative ways to work around the rules.

That appears to be changing. The regulatory framework around the NSA is getting significantly tighter for 2026, and for the first time, I think the law is starting to develop real consequences for non-compliance.

A Quick Refresher on What the NSA Does

The No Surprises Act covers three main scenarios. First, emergency services: you can't be balance-billed for emergency care, period, regardless of whether the hospital or providers are in your insurance network. Second, non-emergency services at in-network facilities: if you go to an in-network hospital but get treated by an out-of-network provider (a common situation with anesthesiologists, radiologists, and pathologists), you're protected from surprise bills. Third, air ambulance services, which were a particularly predatory corner of the healthcare billing universe.

The law also requires providers to give patients Good Faith Estimates of expected charges before scheduled services. If the final bill exceeds the estimate by $400 or more, patients can dispute it.

On paper, this is comprehensive and patient-friendly. In practice, it's been uneven.

What's Changing in 2026

Several things are tightening up. CMS has finalized new rules that increase the penalties for providers and facilities that violate the NSA's balance billing protections. The per-violation penalty is going up, and CMS has signaled that it will pursue repeat offenders more aggressively.

The Good Faith Estimate requirements are also being expanded. Originally, the detailed estimate requirement only applied to uninsured and self-pay patients. Starting in 2026, insured patients will also be entitled to an Advanced Explanation of Benefits that shows expected costs, including the insurer's negotiated rate and the patient's estimated cost-sharing. This has been delayed multiple times, but it appears to finally be moving forward.

The independent dispute resolution (IDR) process is getting an overhaul too. The backlog has been enormous (over 300,000 pending disputes at one point), and the system essentially ground to a halt. New rules streamline the process and set timelines that should prevent the kind of indefinite delays that have plagued it.

Why This Matters Beyond Surprise Bills

The No Surprises Act and hospital price transparency rules are often discussed separately, but they're really two parts of the same project. Price transparency gives patients information before they make a decision. The NSA protects them after the decision is made. Together, they're supposed to create a system where patients can compare prices, choose a provider, and have confidence that the final bill won't be wildly different from what they expected.

In reality, these two pieces haven't connected well. The transparency data is spotty (79% of hospitals aren't fully compliant, as we've discussed). The NSA's protections have been inconsistently enforced. And the consumer experience of navigating either system is terrible.

What I find promising about the 2026 changes is that they start to bridge this gap. The Advanced Explanation of Benefits, in particular, is significant because it will give insured patients a pre-service cost estimate that uses actual negotiated rates. That's essentially what Panopticare already does by cross-referencing hospital chargemaster data with Transparency in Coverage filings, but having it come officially through the insurer adds another layer of verification.

The Enforcement Question

I've learned to be cautiously optimistic about healthcare regulation. The rules can say whatever they want, but what matters is whether they're enforced consistently enough that providers actually change their behavior.

The NSA's track record on this has been mixed. The Consumer Financial Protection Bureau has started getting involved, investigating medical debt practices that may violate the NSA. Several state insurance commissioners have launched their own enforcement programs. And the legal landscape is developing: there have been successful lawsuits against providers who violated balance billing protections, which creates case law that strengthens the statute over time.

But the fundamental challenge remains: the healthcare industry is enormous, the number of potential violations is huge, and the enforcement agencies are relatively small. This is why I keep coming back to the idea that transparency tools and consumer awareness are essential complements to regulation. The government can set the rules and establish penalties, but it can't audit every bill from every hospital. Informed patients and transparent data create a distributed enforcement mechanism that scales in a way government enforcement never will.

The NSA getting teeth is good news. But the real progress will come when patients have both the protection of the law and the information to make good decisions before they ever need it.