The No Surprises Act (NSA) was introduced to protect patients from unexpected medical bills—but it’s billing professionals, providers, and revenue cycle leaders who are now navigating its dense regulatory maze. In a recent webinar hosted by HBMA and presented by James Greenspan of Gottlieb and Greenspan, attendees were given a critical update on how the law is evolving, what pitfalls to watch out for, and how to adapt workflows for compliance and success. This recap highlights the key takeaways from the ImagineSoftware-sponsored session, including Greenspan’s real-world insight into how the law is functioning, and often failing, in practice.
The Law’s Intention vs. Its Reality
The NSA’s core goal was to eliminate surprise medical bills by ensuring patients aren’t stuck in the middle of out-of-network reimbursement disputes. And by that measure, it’s working.
“The overarching goal of the law seems to have been accomplished, which was keeping the patients out of the middle.” —James Greenspan
But for providers and billing companies, the law has created a highly technical, time-sensitive process riddled with ambiguity, especially in bifurcated states like New York, New Jersey, California, and Texas, where state-level and federal laws overlap.
State vs. Federal Jurisdiction: Understanding the Divide
Before the NSA, cross-border care often led to jurisdictional gaps.
Now:
- State laws apply to fully insured plans.
- Federal law (NSA) applies to self-funded employer plans and out-of-state services.
This distinction is critical. If the wrong dispute forum is used (e.g., submitting to a state board when it’s a self-funded plan), the claim is dismissed. Greenspan explained that plan type dictates which law governs the reimbursement process. Fully insured plans are easier to identify, but self-funded plans require careful examination. Look for indicators like “administered by” or “ASO” (Administrative Services Only) on the card, and don’t hesitate to verify with the payer.
What Makes a Case Eligible for NSA Arbitration?
To fall under the NSA, a case generally must involve:
- An out-of-network provider treating a patient at an in-network facility
- A surprise or non-emergency planned procedure where the patient had no meaningful choice of provider
- A self-funded insurance plan (federal jurisdiction) or no applicable state law
Greenspan highlighted that even scheduled cases may qualify if a CMS waiver form wasn’t signed. Patients often aren’t aware an out-of-network provider is involved, and the law assumes they’re not capable of anticipating it.
“Congress defaulted to protecting the patients… Congress assumed patients don’t know enough to ever anticipate there being an out-of-network doctor at an in-network facility.” —James Greenspan
Forms That Matter: Disclosure and Waiver
There are only two forms recognized under NSA—and they must be CMS-issued:
- Disclosure Form
- Must be given to every patient at intake
- Informs them of their NSA rights
- Required for all out-of-network providers
- Waiver Form (a.k.a. Notice and Consent Document)
- Only used if the provider intends to balance bill the patient
- Must be signed in advance
- Most providers choose not to use this form to preserve arbitration rights
“If it isn’t these specific forms, it doesn’t qualify under the law… A financial acknowledgment form from the doctor does not count.” —James Greenspan
The Nightmare Timeline: 30 Days, Then 4
The biggest trap in the NSA process? The unforgiving timeline:
- EOB Receipt – Starts the clock: 30 business days to initiate “Open Negotiation.”
- Open Negotiation Period – After the letter is sent, you wait 30 more business days.
- Arbitration Filing – If the carrier doesn’t settle, you have only four business days to file your arbitration case.
“That is an insanely short period of time… This is something that might eventually get appealed as improper because it seems so clearly targeted at preventing doctors from filing.” —James Greenspan
Greenspan recommends building automated systems or outsourcing this process—manual tracking isn’t sustainable at scale.
Arbitration Rules: One Code, One Case
Unlike other forums (e.g., no-fault or workers’ comp), NSA arbitration is CPT-code specific:
- Each CPT code can be filed independently.
- You can’t bundle codes unless they’re for the same patient, same date, same provider, and same service category.
That means a four-line claim might require four separate arbitration filings, each with its own paperwork, negotiation letter, and timeline.
Watch for Denials That Still Qualify
Not every denial disqualifies a case from arbitration.
Eligible:
- Denials where the patient is not held responsible (e.g., claim denied but patient is held harmless).
Not Eligible:
- Denials placing the burden on the patient, such as those citing lack of medical necessity or non-covered service.
“If the carrier says the patient owes nothing, it’s likely eligible. But if they say the patient owes everything, that’s not eligible for arbitration.” —James Greenspan
Carrier Tactics: Delay and Lowball Offers
Insurers are actively using tactics to delay EOBs, ignore negotiation letters, and issue extremely low payments, hoping providers either miss deadlines or accept unfair reimbursement.
Greenspan noted:
- Less than 1% of carriers respond to negotiation letters.
- Carriers often wait until the last day of negotiation to engage, forcing providers to scramble for arbitration.
CMS Portal Issues & Enforcement
The federal arbitration portal is improving, but still buggy:
- Document upload errors
- Inconsistent communication from arbitrators
- Varying quality of IDR entities
CMS recently acknowledged the flaws, stating: “We understand the law as written is unworkable.” Even so, enforcement primarily targets providers, not carriers. Filing late or submitting invalid documentation leads to instant dismissal. Meanwhile, insurers face little consequence for ghosting providers.
What’s Coming Next?
Greenspan outlined areas where CMS is expected to issue further guidance:
- Denials and eligibility clarification
- Good faith estimates for self-pay/uninsured patients
- Loosening or clarifying batching rules
These updates may reduce provider burden—but for now, vigilance is critical.
Practical Advice for Billing Companies & Providers
- Track every EOB: Use software to set alerts for deadlines per CPT code.
- Only use CMS forms: Improper forms disqualify your case.
- Prioritize high-dollar codes: If arbitration resources are limited, go where the money is.
- Don’t wait for payers: They are unlikely to engage in good faith.
- Stay current: CMS guidance changes frequently—check HBMA, CMS, and payer sites often.
- Outsource if overwhelmed: There are vendors who specialize in managing NSA cases effectively.
Conclusion: Success Under NSA Is Possible—But Only with Structure
The No Surprises Act is here to stay, and while it protects patients, it burdens providers with tight timelines and complex rules. As Greenspan summarized, success under this law requires:
“Deep operational tracking, airtight documentation, and a proactive mindset. Providers who treat this like an afterthought will simply lose money.” —James Greenspan
Billing companies are uniquely positioned to help practices navigate this maze—but only if they understand the rules, automate compliance, and act fast.
Webinar presented by:
James Greenspan, Esq.
Sponsored by ImagineSoftware
Hosted by HBMA
All information contained herein is intended as general introductory information, is provided for informational purposes only, and is not legal advice. It should not be construed as legal advice and should not be relied upon as such. If necessary, please contact an attorney to obtain advice with respect to any particular issue or problem that may be related to the subject matter herein. The ideas and opinions expressed herein are the ideas and opinions of the presenter referenced or individual author and may not reflect the ideas or opinions of ImagineSoftware, Technology Partners, LLC or any of its affiliates or subsidiaries.
