The No Surprises Act still shields patients from emergency balance billing, but insurers are refusing to pay doctors’ arbitration awards in many cases.
What The November 3 Reports Say
The New York Times reported on November 3 that insurers are withholding payments after providers win disputes under the No Surprises Act, which took effect in 2022. The law bars certain surprise bills and routes eligible insurer-provider payment disputes to arbitration. An arbitrator selects one side’s proposed amount, and the insurer is required to pay the award within 30 days, according to The New York Times.
The Times reported that an analysis of 400,000 awards from billing firm HaloMD found nearly 30% had gone unpaid since 2024. In the analysis, Anthem had the highest reported nonpayment rate, at 74% overall and 83% in 2026. Cigna, UnitedHealthcare and Aetna also reportedly left significant portions unpaid. These figures reflect the analysis reviewed by the Times; they are not a complete government audit.
The report described awards ranging from $73,000 for an ankle X-ray to $440,000 for a breast reduction and $125,000 for assisting on prostate surgery. Providers say unpaid awards are affecting operations. Flight for Life, a Wisconsin medevac service, said Anthem owed it $2.1 million for helicopter flights. PHI Air Medical cited $16.3 million in outstanding Anthem payments when it closed a California base. A North Carolina emergency physician group reported $1.2 million in unpaid awards and said it used a credit line to meet payroll.
KFF Health News also covered the dispute on November 3. Insurers argue that some claims should not have qualified for arbitration and that some awards are inflated. Those are insurers’ characterizations, disputed by providers and not independently established by the reported data. Insurers have also criticized billing firms’ role in the process and said arbitrators’ per-dispute fees may create incentives around eligibility decisions.
What It Means For A Patient’s Bill
The dispute described in the reports is between insurers and providers over payment. It does not, by itself, cancel patient protections or make a patient responsible for an arbitration award.
The No Surprises Act’s consumer protections are separate from the payment dispute and remain in effect. Under the law, a patient generally cannot be balance-billed for emergency services, for certain out-of-network services received at an in-network facility, or for air ambulance services. Cost sharing for those services is generally limited to the amount that applies to in-network care. The protections do not extend to all out-of-network care; the specific service and circumstances matter.
The CMS’s No Surprises Act page explains consumer protections and provides information about billing concerns. The federal No Surprises Help Desk can be reached at 1-800-985-3059. Plan terms, state law and service details can affect how a particular claim is handled. A bill should be checked against the plan’s Explanation of Benefits (EOB).
Why The Payment System Is Under Scrutiny
The arbitration process was intended to resolve payment disputes without making patients responsible for negotiating between providers and insurers. But enforcement is a central problem in the current standoff. According to the Times, three federal appeals courts have ruled that providers do not have a private right to sue under the law over unpaid awards. The law allows CMS to fine insurers $100 per day for nonpayment, but the Times reported that no such penalty had been issued. CMS has said insurers are required to pay awards. The Labor Department is investigating Anthem’s nonpayments involving large employer plans, according to the report.
There is also disagreement about the process’s costs. Georgetown’s Center on Health Insurance Reforms estimated that the arbitration process generated $22.4 billion in costs over its first four years, with providers winning about 85% of disputes in 2025. The estimate includes additional award payments and administrative costs; it is not a measure of the amount patients owe. Georgetown’s analysis is available at CHIR.
For people buying individual coverage, the dispute is part of a broader affordability picture, but it is not the sole explanation for premium changes. KFF reported that average 2027 ACA benchmark silver premiums rose about 13%. Premium rates also reflect medical costs, market conditions and other factors. The arbitration process’s costs and withheld awards could affect future negotiations and payment decisions, but their individual effect on any particular plan’s premium is not established. The direction Congress takes, stronger enforcement or a replacement for arbitration, will influence how payments are determined going forward. KFF’s 2027 Marketplace overview provides more detail on premium changes and enrollment issues.
No Surprises Act Timeline
| Period | Recorded development |
|---|---|
| 2022 | The No Surprises Act takes effect and establishes federal protections and an arbitration process for certain payment disputes. |
| 2024 onward | The Times’ analysis found nearly 30% of reviewed awards unpaid since 2024. |
| 2025–2026 | Three federal appeals courts rule that the law provides no private right to sue over unpaid awards, according to the Times. |
| November 3, 2026 | The Times and KFF Health News report on insurer nonpayment and the enforcement dispute. |
| Pending | A penalty bill from Rep. Greg Murphy; a flat-payment proposal from Rep. Frank Pallone Jr.; Sen. Bill Cassidy’s stated effort to address the law before January; a Labor Department investigation of Anthem; and CMS’s unused $100-per-day fine authority. |
If An Emergency Or Air-Ambulance Bill Arrives
The following steps can help identify whether a bill reflects protected cost sharing or a possible billing issue. The appropriate process can vary by plan and state.
- Check the service and network details. Confirm whether the bill is for emergency care, an air ambulance or covered out-of-network services at an in-network facility. Those categories may receive No Surprises Act protections.
- Compare the bill with the EOB. Review the insurer’s claim decision, the service description and the in-network cost-sharing amount. Contact the plan if the EOB is missing or unclear.
- Dispute an apparent extra balance in writing. If a provider bills above the applicable in-network cost sharing for a protected service, ask the provider to review the bill and cite the No Surprises Act. Keep a copy of the request and response.
- Use the applicable process if uninsured or self-pay. A patient who receives a bill at least $400 above the good-faith estimate may be eligible for the patient-provider dispute resolution process. Confirm eligibility and filing requirements before submitting a dispute.
- Contact the Help Desk or state insurance department. The No Surprises Help Desk is 1-800-985-3059. A state insurance department may also accept complaints, depending on the plan and issue.
- Keep the records. Retain bills, EOBs, estimates, claim decisions, letters, call dates and names or reference numbers.
Options For Addressing A Bill
| Option | Useful for | Record to keep |
|---|---|---|
| Dispute directly with the provider | A bill that appears to exceed protected cost sharing | Written dispute and provider response |
| Contact the federal Help Desk | Questions about federal protections or a possible violation | Call date, reference details and guidance received |
| File with the state insurance department | A complaint involving a state-regulated plan or billing matter | Complaint confirmation and supporting documents |
| Request an itemized bill and discuss charges | Understanding charges or addressing amounts not resolved through the protections | Itemized statement and any written agreement |
What May Change Next
The current gap is a policy and enforcement problem: Congress created a payment mandate, courts have limited providers’ ability to enforce it through private lawsuits, and the federal fine authority has not been used, according to the Times. Congress is considering different approaches. One would strengthen penalties for nonpayment; another would replace arbitration with flat payments tied to insurers’ typical rates. The results could change provider payments and the costs plans account for in future coverage years.
Neither the arbitration awards nor the insurers’ allegations establish what a patient owes. Patients with a bill should confirm the service, applicable protections and plan cost sharing using the EOB and written billing records. Current requirements and the status of a specific claim should be independently confirmed.