United States Capitol Building

Surprise/Balance Billing


Surprise medical billing, or “balance billing” of out-of-network medical care, is one of the most pressing health and affordability challenges facing patients and their families, with millions of Americans receiving unexpected and unaffordable medical bills every year. These bills often include exorbitant charges that are far greater than in-network rates and can cost consumers thousands or even tens of thousands of dollars.

UPDATE! On December 21, 2020, Congress banned surprise billing as part of the end of the year Omnibus COVID package. This surprise-billing ban will hold patients harmless from surprise medical bills, including from air ambulance providers, by ensuring they are only responsible for their in-network cost-sharing amounts in both emergency situations and certain non-emergency situations where patients do not have the ability to choose an in-network provider. For other claims, this new surprise-billing agreement utilizes arbitration. However, this bill does require the arbiter to consider the median in-network rate for the service in question. There are many aspects of this section that will ultimately be left up to regulators, and NAHU will work with the federal agencies at every step of the way to ensure that this surprise-billing ban is executed in a way that works best for employers and consumers.



  • There is no active legislation on this issue.


There are many aspects of the recently passed surprise billing ban that will ultimately be left up to regulators, and NAHU will work with the federal agencies at every step of the way to ensure that this surprise-billing ban is executed in a way that works best for employers and consumers.


  • There are no active Operation Shouts on this issue.


Millions of patients face medical bills they did not expect at prices they cannot afford. According to a Kaiser Family Foundation poll, 41% of insured adults ages 18-64 said they received a surprise bill in the last two years.

While the majority of doctors and providers do their best to deliver fair, affordable care for patients and their families, there is a small but significant number of doctors and hospitals responsible for the vast majority of surprise billing. When clinical specialists choose not to participate in health insurance providers’ networks – or if they do not meet the standards for inclusion – they often demand a blank check from patients for their services.

The consequences are significant: financial stress; fighting a complicated, confusing bureaucracy; harassed by collection agencies; and often legal action for non-payment. And when a health insurance provider steps in on a patient’s behalf to cover the surprise medical bill, it raises premiums for everyone else.

NAHU supports meaningful improvements that would: protect patients and families from surprise medical bills; maintain fair and equitable payments for providers with a federal benchmark standard; and help reduce consumers’ health insurance premiums by avoiding a costly arbitration process and addressing the inflated bills that make health care more expensive. We are advocating four primary solutions to curb the practice of surprise billing:

  • Ban balance-billing when patients inadvertently see out-of-network providers.
  • Reimburse providers based on the negotiated rate for that service.
  • Establish an independent dispute resolution process, but not arbitration.
  • Require hospitals disclose out-of-network physicians in non-emergencies.


  • Surprise medical billing is one of the most pressing affordability concerns facing patients today. More than four in ten insured adults said they received a surprise medical bill from an out-of-network provider in the past two years.
  • These bills often exceed hundreds, even thousands of dollars. At a time when nearly 40 percent of Americans cannot afford a $400 emergency, surprise medical bills shouldn’t break the bank.
  • Ending the unfair practice of surprise medical billing would solve a major health challenge facing patients while enhancing financial security for millions of Americans. 
  • For non-emergency situations, patients deserve to know who will be treating them and whether they are in their insurance network. Hospitals should notify patients at their first point of contact that some providers assigned to them may be out-of-network and inform them of their right to select in-network providers or decline care. 
  • Establishing a federal benchmark would ensure patients who are treated by out-of-network providers, largely clinical specialists and hospitals that opt against participating in-network, still benefit from negotiated rates.
  • Bench-marking would also avoid the arbitration process that can lead to an increase in premiums that are ultimately paid by consumers and employers;. it is estimated that this could save consumers more than $25 billion over ten years.

Podcast episode on New York arbitration method: