No Surprises Act Collections Toolkit

Overview: The No Surprises Act and Its Impact on Collections

Effective January 1, 2022, the No Surprises Act (NSA) ushered in sweeping protections for patients against surprise medical bills. This law, part of a bipartisan effort, fundamentally changed how providers can bill patients for certain out-of-network care. As a result, hospital and physician collection practices had to adapt quickly to remain compliant and transparent. 

What is a “surprise bill”? Typically, it’s an unexpected balance bill the patient receives for out-of-network services they didn’t knowingly choose – classic scenarios are ER visits or an out-of-network anesthesiologist at an in-network hospital. Prior to NSA, a patient might get a bill for the out-of-network charges not covered by insurance (often thousands of dollars). The NSA largely bans this: patients are only responsible for in-network cost-sharing amounts in these situations. 

Key provisions of the No Surprises Act that affect collections:

• Emergency services: Patients can’t be balance-billed for emergency care at an out-of-network facility or by out-of-network providers. They pay no more than the in-network deductible/copay.
• Non-emergency care at in-network facilities: If a patient goes to an in-network hospital, any out-of-network providers there (radiologists, anesthesiologists, etc.) cannot balance bill the patient. Those providers must work it out with insurance or go to arbitration if needed.
• Air Ambulance: Out-of-network air ambulances can’t balance bill beyond the in-network cost sharing.
• Notice and consent exception: The only time balance billing is allowed is if a patient is electively seeing an out-of-network provider at an in-network facility and voluntarily signs a detailed consent at least 72 hours in advance, after receiving a cost estimate. Even then, some types of providers (like anesthesiology, pathology, etc.) cannot use this exception – they’re always barred from balance billing at in-network facilities.
• Good Faith Estimates (GFE) for self-pay patients: Providers must give uninsured or self-pay patients a Good Faith Estimate of expected charges before service (at least 3 business days in advance for scheduled care). If the final bill exceeds the GFE by $400+, the patient can dispute the charges via a new arbitration process.
• Patient-Provider Dispute resolution: Mechanism for self-pay patients to challenge bills higher than the GFE. While this is separate from insurance, it still means providers must handle these disputes, and cannot send these contested bills to collections while resolution is pending.
• Disclosure requirements: Providers must publicly post and give to patients a one-page notice of their NSA rights (no surprise billing, how to contact state/federal agencies, etc.). This must also go on billing statements for any balance billing attempts that are allowed (with consent).
• Penalties: The law imposes civil monetary penalties up to $10,000 per violation for providers who willfully violate the balance billing protections (though providers can avoid a penalty by withdrawing the bill and refunding the patient within 30 days of discovering an error).

All these provisions mean that collection teams must be extremely careful about which balances they pursue from patients. A previously typical scenario – sending a big out-of-network ER physician bill to collections – is now illegal if it falls under NSA. The financial burden in those cases shifts to insurers and providers to sort out via negotiated rates or arbitration.

Moreover, communications and billing practices with patients have to reflect NSA requirements:

• Including the NSA notice in any applicable billing.
• For any patient who got a GFE (like a self-pay surgery estimate), if they call disputing the bill, immediately pause collections and guide them to the dispute process (or correct the bill if an error).
• Ensuring no collection action (like reporting to credit bureau, etc.) occurs on an NSA-protected balance. For instance, you wouldn’t send a surprise bill to collections; you’d instead go through the insurer or arbitration.

For compliance and good patient relations, providers need a “toolkit” of updated processes, form letters, and scripts that incorporate these rules. This Toolkit will provide those elements: from sample NSA disclosure text, to template consent forms, to suggested billing workflows that align with the law.

Bottom line: The No Surprises Act aims to remove patients from the middle of billing disputes. Providers and collectors must adjust by (a) correctly identifying when a patient should not be billed or only billed a limited amount, (b) clearly communicating to patients their rights and what they do owe, and (c) handling any billing issues through the appropriate channels rather than aggressive collections.

This is not just about compliance to avoid penalties – it fundamentally improves the patient financial experience, which can build goodwill. A survey prior to the NSA found nearly 1 in 5 emergency room patients received a surprise out-of-network bill, often costing $750-$2,600 on average. Eliminating those nasty surprises helps patients trust the system more and prevents medical debts that lead to personal financial ruin or avoidance of care.

Now, let’s dive into how to operationalize these requirements and use our Toolkit resources.

Section 1: Compliance Checklist for NSA in Collections

Before jumping into templates, use this quick checklist to ensure your collections process aligns with the No Surprises Act:

• Flag NSA-protected accounts: Establish a system to mark accounts that involve services covered by NSA (e.g., out-of-network ER, ancillary at in-network hospital). These should be suppressed from any balance-billing collections. Coordination between billing and collections IT systems is crucial. For example, if a claim comes back with an insurance payment and a remark code indicating the patient is not liable under NSA, that balance should never hit the patient’s bill.
• Update billing statements: All patient bills for services on or after January 1, 2022, should include a plain-language NSA notice if applicable. The notice should explain that the patient is not being billed more than their in-network share for certain services. Even for typical bills, providers must include a statement about NSA rights. Our Toolkit includes a sample disclosure (see Template A).
• Training staff and vendors: Train your patient financial services staff and any third-party collection agencies on NSA basics. They should know phrases like “balance billing” and situations to watch for. For instance, if a patient says, “I have insurance, why am I getting this out-of-network charge?” your staff should investigate if it’s an NSA scenario. Also, if using early-out or collections vendors, ensure their scripts incorporate checking “Is this a surprise bill scenario?” and cease collection and refer back if so.
• Good Faith Estimate integration: For uninsured/self-pay, make sure when you send the initial GFE, and if the patient proceeds with service, that estimate is stored. When billing, compare actual charges to the GFE. If the bill is significantly higher, include a notice about their right to dispute. Do not send these bills to collections quickly – the patient has 120 days to initiate a dispute from the billing date. It’s wise to hold such accounts for that window before any collections. Our Toolkit provides a template letter for instances where charges exceed the estimate, inviting the patient to contact us or use the dispute process (Template B).
• Payment posting and refunds: If a patient was mistakenly balance-billed and pays, you have a process to promptly refund the overage plus interest if needed. Also, commit to withdrawing any collections or credit reports on that amount (the law requires this within 30 days of identifying the error to avoid penalties).
• State law overlay: Many states already had surprise billing laws. NSA largely defers to state law for determining payment amounts if a state law exists. But for collections, the patient protections are similar. Ensure compliance with any additional state-specific notices or timing. For example, some states require a specific disclosure form or use their own arbitration. The Toolkit includes a summary of major state requirements (or references where to find them) so you can incorporate those as needed.
• Audit for compliance: Periodically sample some accounts (especially complex ones like surgeries with multiple providers) and ensure no improper patient bills went out. Check that your staff are using the NSA consent form correctly for any allowed out-of-network waivers. Ensure GFE processes are running smoothly and that no disputes from patients fall through the cracks. It might be helpful to keep an NSA log of any surprise billing complaints or disputes filed by patients to track resolution.

By using this checklist, you create a controlled environment where patients are no longer surprise-billed and your collections are focusing only on appropriate balances.

Section 2: NSA-Compliant Patient Communication Templates

Clear communication is a cornerstone of NSA compliance. Patients must be informed of their rights and what they owe in a straightforward way. This Toolkit provides templates you can customize:

Template A: NSA Patient Rights Disclosure (for billing statements)

Every billing statement for services that could involve NSA protections should include a concise notice. Example:

Important Information About Your Rights: You’re protected from surprise billing. Under federal law, you cannot be required to pay more than your in-network cost-sharing for emergency services, or for certain care at an in-network facility by out-of-network providers. If you were charged more or have questions, please call us at 1-800-XXX or visit cms.gov/ nosurprises. If you believe you’ve been wrongly billed, you may contact the No Surprises Help Desk at 1-800-985-3059.

This text can be adjusted to fit on statements (usually in the back or a separate insert). Keep it to a short paragraph. Our provided text uses plain language (no jargon like “balance billing” without explanation). We also include the official help line.

Template B: GFE Exceeded – Patient Options Letter

If your charges exceed the Good Faith Estimate by $400+, proactively inform the patient of their options:

“Dear [Patient Name],

We previously provided a Good Faith Estimate of $[X] for your [Service]. Your final bill was $[Y], which is higher than expected. We understand this can be concerning.  

Your Rights: Because the final amount is at least $400 above the estimate, you have the right under the No Surprises Act to initiate a dispute resolution process. This independent process could determine a fair payment amount.

What You Can Do: – You can contact us to discuss the charges. We’re happy to provide a detailed breakdown and check for any possible errors or insurance reprocessing. If you prefer to use the formal dispute process, you need to start it within 120 days of receiving this bill. Visit the CMS No Surprises Act website or call 1-800-985-3059 to learn how to submit a dispute claim.

We value transparency and want to help you navigate this. If you have questions or think part of this bill is incorrect, please reach out to our billing advocates at [phone] or [email]. 

(If you’ve already paid more than the in-network amount for any services covered by these protections, we will refund the difference to you.)

Sincerely,
Billing Department, [Your Hospital]”

This letter template, provided in the Toolkit as a Word file, ensures the patient is made aware of their right to dispute. Often, working it out directly is simplest, but by mentioning the formal option, you empower the patient and protect yourself. If you send this kind of letter as soon as you identify a bill qualifying for dispute, it can prevent the scenario where a patient feels ignored and files a complaint.

Template C: Consent to Out-of-Network Charges Form

In rare cases where a patient can and does waive NSA protections (e.g., choosing an out-of-network specialist at an in-network facility), you must use the standard Notice and Consent form. The law even provides a model form. Our toolkit includes a copy of the model with areas to fill in: –

• It must itemize the services and give a good-faith cost estimate.
• Clearly state that by signing, the patient gives up their balance billing protections.
• It can’t be signed under duress or too close to the service (must be in advance).
• We include a checklist for staff: ensure it’s not a type of provider who cannot ask for consent (like anesthesiology, radiology – list of those forbidden categories), ensure it’s given with required advance time, and a copy is provided to the patient.

Using this form properly is critical. If it’s done incorrectly, the consent is invalid, and you cannot balance bill. Many providers avoid using this at all due to complexity. But if you do, our toolkit’s checklist and sample will help you do it right.

Template D: State-Specific Disclosures Addendum

If your state has additional requirements, use this addendum in patient communications: For example, New York requires hospitals to have a patient financial services guide; Texas has its own balance billing law for emergencies (though NSA overrides parts, state enforcement might require Texas-specific notice).

We provide an addendum template where you can slot in state law info:

• “For New York residents: You are also protected by New York’s surprise billing law. Visit [NYDFS website] for information or call [state helpline].”
• Similar blurbs for states like California, Florida, etc., are included as needed.

Providers should include the applicable state notice along with the federal one, or a combined notice if possible.

By implementing these templates, your patient communications regarding billing will be compliant, clear, and helpful. They reduce confusion, which is key because confusion often leads to non-payment. A survey found 37% of patients won’t pay a bill they find confusing. We want to eliminate confusion, especially in these sensitive surprise billing situations.

Section 3: Workflow Adjustments and Staff Training Tips

Beyond the written communications, it’s about adjusting internal workflows and ensuring your staff (and any partners) execute properly. Here are some key adjustments to institutionalize:

• Pre-service workflow for self-pay: When scheduling an uninsured or self-pay patient, trigger the creation of a Good Faith Estimate. Train scheduling or financial counseling staff to use our GFE template (the Toolkit includes a sample GFE form or system printout guide). Also, flag the account in your billing system as having a GFE and track the $ estimate. Then, after service, when charges are posted, have the billing system compare actual vs GFE. If beyond the threshold, automatically generate the Template B letter or at least alert a rep to review.
• Insurance billing workflow: Educate coders/billers on using modifiers required by NSA. For instance, use the CMS “GB” and “GU” modifiers as appropriate on claims to indicate if a notice-and-consent was obtained (GU) or not required (GB) for certain out-of-network services. This helps payers process correctly and avoids mistaken denials or patient billing errors.
• Patient intake: Front desk and registration should hand every patient (or include in digital portals) the one-page surprise billing notice. This is part of compliance. Also, post it in your facilities (the law requires public posting). The Toolkit provides a poster example you can print for waiting rooms, etc., and a PDF for your website.
• Back-end collections hold: Program your collections system to hold any account that has an open NSA dispute or arbitration. If a patient or insurer notifies you that a dispute resolution is initiated, immediately flag that account to prevent any outbound collections. This is crucial – attempting to collect during the dispute process could violate the law. Designate a point person (maybe a billing supervisor or patient advocate) to manage NSA cases, so they can coordinate between legal, finance, and the patient.
• Training session content: Conduct training with real-life scenarios:
  • Example 1: Out-of-network surgeon at in-network hospital, no consent – ask staff how to handle.
    • Correct answer: Treat it as NSA protected; bill the patient only the in-network amount. The rest goes to insurer negotiation/arbitration if needed.
  • Example 2: Patient got a GFE of $1200 for a procedure, but complications arose, and the bill is $2000. What do we do?
    • Answer: Bill the patient for $1600 ($1200 + $400 tolerance) unless they willingly pay more, and inform them of dispute rights for the rest $400. Possibly proactively not charge beyond $1600 pending dispute outcome to be safe.
  • Example 3: Patient calls with a surprise bill from an anesthesiologist – talk through how customer service should respond (apologize for the confusion, confirm they shouldn’t have gotten that bill, immediately pull it back, reassure them they only owe an in-network amount, etc.). Role-playing builds confidence
• Coordinate with payers: The NSA sets up that insurers will send an initial payment or denial and then providers can open independent dispute arbitration if needed. Your billing office should have a process: If you believe you’re underpaid on an NSA claim (insurer paid too low), you have 30 days to initiate arbitration. While that’s more payer relations than patient collections, it affects revenue. Set rules for which cases to arbitrate (probably high-value ones, since arbitration costs fees). Meanwhile, never involve the patient in that balance – that portion stays off their bill entirely.
• Ensure Charity and Assistance are easy: One reason surprise bills were so devastating is that patients didn’t expect them, and often can’t pay. Under the NSA, many such bills vanish, but patients still have other medical bills. Emphasize your hospital’s financial assistance options in all communications to keep goodwill. E.g., include a line “If you’re unable to pay the amount you do owe, we have financial counselors to help with payment plans or aid.” This mitigates complaints and shows regulators you’re acting in good faith.

By refining workflows and continuously educating staff, compliance with the No Surprises Act becomes a standard part of your operations rather than a daunting new task. 

Section 4: Toolkit Resources – What’s Included

In this Toolkit, you’ll find:

• NSA Compliance Checklist (PDF): A one-page checklist summarizing actions to take (like the ones above) for quick reference.
• Template Library (Word Docs):
  • NSA Billing Disclosure Paragraph (multi-language versions for common patient languages as needed),
  • Good Faith Estimate form (with required elements per CMS),
  • Notice & Consent form (the official model, plus our staff checklist to use it correctly),
  • Patient letter templates (for GFE variance, etc., as discussed).
• Staff Training Slides (PPT): A short slide deck you can use internally to train employees on NSA – covering what it is, why it matters, dos and don’ts in billing. Includes scenario Q&A.
• State Law Reference Guide (PDF): A table of state surprise billing laws and how they intersect with NSA, for your reference. This helps if you operate in multiple states or need to incorporate state-specific rules.
• FAQ for Collections Staff: A list of frequently asked questions (with plain-English answers) that frontline billing or call center staff can use. E.g., “Can I ever send a surprise bill to collections?” – Answer: “No, if protected by law, we only bill them their in-network share. Anything else is handled with the insurer.”
• Patient Education Brochure (PDF): Optional, but we include a simple brochure explaining surprise billing protections that you could share with patients (e.g., in registration packets). An informed patient is less likely to panic or lash out if confusion arises.

Using these tools, your hospital can create a robust compliance program around the No Surprises Act and ensure your collections practices are patient-friendly and lawful. The effort you invest in understanding and implementing these changes will pay off in avoiding penalties (up to $10k per violation is a steep fine ) and maintaining trust with your patients.

Conclusion

The No Surprises Act fundamentally shifts parts of the revenue cycle by removing patients from certain billing disputes. For providers, this meant initial adaptation, but ultimately it led to a fairer system. By utilizing this Toolkit and integrating its templates and processes, your organization will not only comply with the law but also demonstrate a commitment to transparent, patient-centered billing.

Patients who no longer receive surprise bills are less likely to delay care or mistrust the billing process. In fact, clear communication about costs can improve the likelihood of them paying the bills they do owe. It’s a positive ripple effect: compliance drives patient goodwill, which drives better collections on legitimate balances.

As with any major change, there will be learning curves. Keep an open feedback loop – if patients or staff spot issues, address them and update your toolkit materials accordingly. The regulatory environment can evolve too (e.g., new federal guidance or state amendments), so stay informed via CMS and industry updates. We’ll endeavor to update this Toolkit for any significant changes.

In closing, by eliminating surprise medical bills, we take a big step toward rebuilding patients’ confidence in the financial side of healthcare. Your revenue cycle can be both compassionate and effective – these goals are not mutually exclusive; in fact, they reinforce each other.

Feel free to reach out with any questions or for further assistance in implementing these tools. Together, let’s make surprise bills a thing of the past and ensure a smoother experience for those we serve.

• Schedule Demo – Interested in software that automates No Surprises Act compliance (from GFE generation to patient billing)? Schedule a demo with our solutions team to see how our platform can streamline NSA workflows and keep you compliant effortlessly.
• Download Toolkit – Ready to put this into action? Download the complete “No Surprises Act Collections Compliance Toolkit” now to get all the templates and checklists mentioned above. Empower your revenue cycle team with these resources and navigate the new era of patient billing with confidence.

No Surprises Act FAQ