A law designed to stop unexpected medical bills. Here's what it covers, what it doesn't, and why it matters before you start any therapy.
You scheduled a therapy appointment, used your insurance, and then the bill arrived — and it was nothing like what you expected. That moment of confusion and frustration is exactly why Congress spent years pushing for what became the No Surprises Act.
This law was built around a simple idea: patients shouldn’t be blindsided by medical bills for care they thought was covered. But like most legislation, the details matter — and the gaps in the law matter just as much as what it actually does. This page gives you a straight answer on what the No Surprise Act is, why it exists, and what it means for you as a patient — especially if you’re receiving physical therapy or occupational therapy on Long Island.
The No Surprise Billing Act — formally known as the No Surprises Act — was signed into law on December 27, 2020, as part of the Consolidated Appropriations Act of 2021. It took effect January 1, 2022. The law was a federal response to a problem that had been building for years: one in five insured Americans had received an unexpected medical bill from an out-of-network provider, and 22% of those bills were for more than $1,000.
The core protection is straightforward: in most situations, you cannot be charged more than your in-network cost-sharing amount for care from an out-of-network provider — if you had no meaningful ability to choose that provider. That most commonly applies to emergency care and to ancillary providers (like anesthesiologists, radiologists, or lab technicians) who are assigned to you at an in-network facility without your input.
The law also created a separate protection for uninsured and self-pay patients: the right to receive a Good Faith Estimate before scheduled services. This is a written document that itemizes expected costs before your first appointment, giving you a real number to plan around instead of a mystery bill afterward.
The most common source of surprise billing wasn’t a shady provider or a billing error. It was a structural flaw in how healthcare networks work. A patient would go to an in-network hospital for surgery, but the anesthesiologist who showed up in the operating room was employed by a separate group that wasn’t in their network. The patient had no idea. They couldn’t have chosen differently — they were unconscious. And then the bill arrived.
This same pattern played out across emergency rooms, imaging centers, and outpatient facilities for years. Patients did everything right — they chose an in-network facility, they verified their coverage — and still ended up with a four-figure bill from a provider they never selected.
Before the No Surprises Act, only a handful of states had meaningful protections in place. New York was actually one of them — the state had enacted its own surprise billing law before the federal version existed. But the federal law created a national floor, meaning every state now has at least the baseline protections the law requires. In New York, patients benefit from both layers — the state law and the federal law — which together offer stronger protections than either would alone.
Only 20% of medical consumers knew what they would fully owe before receiving treatment. That’s not a consumer education problem — it’s a system design problem. Patients were routinely kept in the dark about costs until after the fact, and there was no legal mechanism to force transparency. The No Surprises Act changed that, at least in part.
For seniors on Medicare, the billing landscape had its own complications. Medicare generally prohibits balance billing, so most Medicare beneficiaries had some protection. But Medicare Advantage plans operate on private networks with their own rules, and the intersection of Medicare, Medicare Advantage, and the new federal law left many patients genuinely confused about which protections applied to them.
Here’s where it gets important — and where a lot of patients get caught off guard even after the law passed. The No Surprises Act has real limits, and understanding them is just as valuable as knowing what it does.
The law does not protect you if you voluntarily choose an out-of-network provider for non-emergency services. If you decide to see a physical therapist who is not in your insurance network, and that therapist is not operating within an in-network facility, the balance billing protections generally do not apply. You can still be billed at out-of-network rates. Choosing an in-network or Medicare-certified provider remains the clearest path to predictable costs.
The law also does not cover ground ambulance transport. Air ambulance is protected under the NSA, but if a ground ambulance takes you to a hospital and that ambulance company is out-of-network, you can still receive a surprise bill. This is a known gap in the legislation and has been the subject of ongoing regulatory discussion since the law took effect.
There’s also a consent mechanism built into the law that patients should understand. In certain non-emergency situations, an out-of-network provider can ask you to sign a form waiving your surprise billing protections. If you sign it, you’ve agreed to be billed at out-of-network rates. The law requires that this consent be voluntary and informed — but in practice, patients sometimes sign forms without fully understanding what they’re waiving. Reading anything before you sign it is always worth the extra two minutes.
In the first nine months of 2023 alone, the No Surprises Act protected Americans from more than 10 million surprise medical bills. The problem hasn’t been eliminated, but it’s been significantly reduced — and knowing the law’s boundaries puts you in a much stronger position than most patients.
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Per CMS guidance, the No Surprises Act applies to physical therapists, occupational therapists, and speech-language pathologists — not just hospitals and emergency rooms. This is something many PT and OT patients don’t realize. If you are uninsured or paying out of pocket for therapy, you have the legal right to receive a Good Faith Estimate before your first scheduled session.
That estimate must include a description of the services, the expected billing codes, and your anticipated costs — in writing, before your appointment. If your provider schedules you three or more business days in advance, they are required to deliver that estimate within one business day of scheduling. Providers who fail to comply face penalties of up to $10,000 per violation.
For insured patients, the law primarily protects against balance billing from out-of-network providers in the situations described above. But even if you’re insured, asking your provider upfront about their network status, what your plan covers, and what your expected out-of-pocket costs will be is always a reasonable — and smart — thing to do.
A Good Faith Estimate is a written cost breakdown that a healthcare provider is required to give uninsured and self-pay patients before scheduled non-emergency services. It’s not a bill — it’s a projection. It tells you, before you commit to care, what you’re likely to owe.
The estimate must include your name, the service description, the relevant diagnosis and billing codes, the provider’s name and location, and the expected charges. It has to be specific enough to be useful. A vague range isn’t sufficient — the law requires an itemized estimate that reflects the actual services planned.
Here’s the protection that matters most: if your final bill exceeds the Good Faith Estimate by $400 or more, you have the right to dispute it. The federal government established a Patient-Provider Dispute Resolution process specifically for this situation. You don’t have to simply accept a bill that bears no resemblance to what you were told to expect.
This is a meaningful shift from how medical billing worked before. For years, patients had no legal mechanism to challenge a bill that exceeded an informal estimate. The GFE requirement creates a documented baseline — a number the provider is accountable to. It doesn’t cap your bill, but it gives you standing to push back if the final charges are materially higher than what you were told.
If you’re receiving physical therapy after an auto accident and using no-fault insurance, your billing situation is different from a standard insurance or Medicare claim — and it’s worth understanding why.
No-fault insurance in New York is a first-party coverage system. It pays for your medical treatment regardless of who caused the accident, up to the limits of your policy. The No Surprises Act’s balance billing protections were not designed with no-fault billing in mind — they primarily address the insured-patient and self-pay contexts described above. No-fault has its own regulatory framework under New York State law, including fee schedules that govern what providers can bill for specific services.
What this means practically is that no-fault patients have a different set of protections and a different billing process than someone using standard health insurance or Medicare. The most important thing a no-fault patient can do is work with a provider who understands that system — one who accepts no-fault, knows how to navigate the documentation requirements, and handles the billing directly so the patient can focus on recovering.
We accept no-fault insurance for rehabilitation therapy, and we manage the billing process on behalf of our patients. No-fault billing involves specific documentation timelines, prior authorization requirements, and fee schedule compliance that not every PT or OT practice is equipped to handle. Patients who end up with a provider that doesn’t understand no-fault billing often find themselves caught in the middle of disputes between their provider and the insurance company — which is the last thing anyone needs while they’re trying to recover from an injury.
The No Surprises Act is a meaningful step forward for patients — but it’s not a complete solution, and it doesn’t remove the need to ask good questions before you start care. Know whether your provider is in-network. Ask for a Good Faith Estimate if you’re paying out of pocket. Understand what your plan covers, what your cost-sharing looks like, and whether your provider handles billing directly or leaves that to you.
For most patients, the biggest protection isn’t a law — it’s choosing a provider who operates transparently from the start. One who tells you what to expect before your first session, handles the insurance process on your behalf, and doesn’t leave you guessing until a bill shows up weeks later.
If you have questions about how billing works for in-home or in-clinic physical therapy on Long Island — whether you’re on Medicare, using no-fault insurance, or paying out of pocket — we’re happy to walk you through it before you ever schedule an appointment. Reach us at 631-866-6507.
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