Model Design by Kelly Emrick, DHSc, PhD, MBA, BSRT(ARRT)R
The No Surprises Act
Federal patient protections against unexpected out-of-network medical bills — and what they mean in practice for imaging centers.
Two parts. One law.
For providers, the No Surprises Act operates along two distinct axes. Both apply to outpatient imaging centers — and both create operational obligations.
Balance-Billing Restrictions
When the Act applies, out-of-network providers cannot bill patients beyond the protected in-network cost-sharing amount. Imaging is a protected ancillary specialty.
Good Faith Estimates
Providers must give written estimates of expected charges to uninsured or self-pay patients for scheduled services, or upon request — and retain them for six years.
Three protected scenarios.
The Act protects insured patients in three defined situations — the situations where they had little or no practical ability to choose an in-network provider.
Emergency Services
Out-of-network hospitals, freestanding EDs, or emergency clinicians. Patient pays only the in-network cost-sharing amount.
Non-Emergency Ancillary at In-Network Facilities
Includes radiology, anesthesiology, pathology, neonatology, and similar hospital-based specialties. Waivers generally not permitted.
Air Ambulance Services
Out-of-network air ambulance transport is federally protected. Ground ambulance is generally not covered the same way.
Imaging is on the list.
Hospital-based specialties most often associated with surprise billing — and most often protected by the Act.
Radiology
Imaging interpretationAnesthesiology
Surgical / proceduralPathology
Biopsy / labEmergency Medicine
ED physiciansNeonatology
NICU coverageAssistant Surgery
Surgical supportHospitalist
Inpatient medicineIntensivist
ICU / critical careIn-network rates. Even when the provider isn’t.
When the Act applies, patient cost-sharing cannot exceed what they would have paid at an in-network provider. The protected amount counts toward their in-network deductible and out-of-pocket maximum.
Four steps. Self-pay patients only.
The GFE process is separate from insurance billing. It applies to patients who are uninsured, or who have insurance but choose not to use it.
Identify the patient
At scheduling, flag uninsured or self-pay status.
Build the estimate
Include modality, contrast, professional interpretation, and other expected charges.
Deliver in writing
Provide the GFE for scheduled services, or upon request.
Retain six years
Maintain in the medical record; available upon request.
If an uninsured or self-pay patient receives a final bill at least $400 more than the Good Faith Estimate from a provider or facility, the patient may use the federal patient-provider dispute resolution (PPDR) process. This is why GFEs must be specific, documented, and retained.
What the Act does — and doesn’t do.
The NSA is targeted. It is not a universal protection against every unexpected medical bill.
What the NSA DOES
- Limits patient cost-sharing to in-network levels in protected scenarios.
- Bans balance billing for emergency care and most ancillary hospital-based services.
- Requires Good Faith Estimates for uninsured and self-pay patients.
- Provides a federal dispute pathway when bills exceed the GFE by $400+.
- Counts protected cost-sharing toward in-network deductible and OOP max.
What the NSA DOES NOT Do
- Eliminate deductibles, coinsurance, or copays.
- Require insurance companies to pay every claim submitted.
- Convert all out-of-network care into in-network care.
- Apply to every unexpected or high medical bill.
- Preempt state laws or payer contracts that add requirements.
A critical distinction
The NSA does not prevent collecting patient responsibility after adjudication when properly owed. It does not require accepting an estimated pre-service amount as final. But it does create real legal and financial risk if a protected patient is balance billed in a covered scenario, or if a self-pay patient is not given a proper GFE.
Seven things imaging centers must do.
Compliance touches scheduling, eligibility verification, registration, financial counseling, billing, and records retention. Here’s the operational checklist.
Avoid improper balance billing when the NSA applies
Flag OON claims in protected scenarios and route to compliance review before patient billing.
Provide Good Faith Estimates to uninsured and self-pay patients
Standardize a GFE template by modality (MRI, CT, and other services offered) — generate at scheduling.
Distinguish estimates from final insured responsibility
Dual-disclosure script: insured estimates marked “pending payer adjudication,” self-pay get a formal GFE.
Verify in-network status with the patient’s plan
Run eligibility and benefits at scheduling. Document network status; trigger NSA workflow if OON.
Communicate that insured responsibility finalizes post-adjudication
Include EOB-dependent language on all pre-service estimates and patient statements.
Maintain documentation for six years
Retain GFEs in the medical record. Archive notice-and-consent forms indexed by encounter.
Use compliant notice and consent language where applicable
Use CMS-issued standard forms. Confirm the modality is not on the protected ancillary list before requesting a waiver.
Tell patients clearly whether the service is in-network, out-of-network, self-pay, or insurance-billed. Provide Good Faith Estimates when required. Avoid balance billing in protected situations. And wait for payer adjudication before representing an insured patient’s final responsibility as definitive.