Published December 10, 2021

No Surprises Act Implementation Guide: Hospitals, Their Medical Staffs, and NSA Disclosure and Notice Requirements

No Surprises Act Implementation Guide

This is the third installment of PYA’s No Surprises Act Implementation Guide. The final installment will address claims submission.

Effective January 1, 2022, hospitals and the physicians who furnish services to hospital inpatients and outpatients will be subject to the prohibitions on surprise billing and related provisions of the federal No Surprises Act (NSA).[1] As part of their efforts to comply with these new requirements, hospitals should communicate with their medical staff members regarding the NSA’s requirements and offer to enter into a written agreement with these providers regarding the delivery of required notices to hospital patients.   

NSA Overview 

The NSA concerns billing for emergency services furnished at out-of-network facilities (i.e., hospitals, freestanding emergency departments, and ambulatory surgery centers) and non-emergency services furnished by out-of-network providers at in-network facilities. Generally, the NSA prohibits facilities and providers in these circumstances from charging patients more than they would have owed if they had received the same services from an in-network facility or provider. The NSA details the manner in which a facility or provider determines the appropriate amount to charge the patient and secures payment from the patient’s health plan or issuer. 

Disclosure and Notice Requirements

The NSA requires facilities and those providers who furnish services to facility patients to make certain disclosures to the public on their websites and at their physical locations, and to deliver to patients a one-page notice regarding consumer protections afforded by the NSA (NSA Notice).[2]  [CB1] 

Specifically, a facility must deliver the NSA Notice to all patients who are participants, beneficiaries, or enrollees of a group health plan or group or individual health insurance coverage offered by a health insurance issuer regardless of network status,[3] while a provider must deliver the same notice to those patients for whom the provider furnishes services in a facility or in connection with a facility visit. 

A facility or provider must deliver the NSA Notice to the patient in person or through mail or e-mail (as selected by the patient) no later than the date on which the provider or facility requests payment from the patient or, if the facility or provider does not request payment from the patient, the date on which the facility or provider submits a claim to the plan or issuer.[4]

Avoiding Unnecessary Duplication

HHS has recognized the practical challenges associated with providers having to deliver notices to facility patients for whom they provide services, and the confusion likely to ensue when these patients receive multiple notices. Therefore, HHS has crafted a limited exception to the notice requirements for providers furnishing services in a facility or in connection with a facility visit.   

Specifically, a provider is not required to deliver the NSA Notice to any patient receiving services at the facility if—and only if—the provider has a written agreement with the facility under which the facility assumes responsibility for delivering the NSA Notice on the provider’s behalf. If the facility fails to provide full or timely disclosure information, then the facility, but not the provider, violates the disclosure requirements regarding surprise billing protections. Note that the exception does not relieve a provider of its obligation to make the required disclosures on its public website and at its physical location.

The relevant regulation—45 CFR 149.430(f)—does not otherwise specify the terms of the written agreement. “HHS clarifies that a ‘written agreement’ may be an existing contract between the provider and facility to furnish care at the facility, if amended to provide for this special rule. Alternatively, a provider and facility may enter into a new written agreement specifically outlining the disclosure requirements regarding balance billing protections.”[5]

In preparing for the January 1, 2022, compliance date, a hospital should consider communicating with members of its medical staff regarding NSA requirements and offer to enter into written agreements with these providers regarding the delivery of the NSA Notice to hospital patients. The contents of this article may be helpful in crafting such communication. 

For illustration purposes only, PYA has prepared the following sample written agreement. The SAMPLE AGREEMENT DOES NOT CONSTITUTE LEGAL ADVICE; hospitals and providers should consult with qualified legal counsel regarding their specific circumstances.


For assistance with NSA compliance, or with any matter involving compliance, valuation, or strategy and integration, one of our executive contacts would be happy to assist. You may email them below, or call (800) 270-9629. 

[1]  The NSA also requires providers to furnish good faith estimates of charges to self-pay patients in specified circumstances. This NSA requirement is beyond the scope of this article.

[2] The Department of Health and Human Services (HHS) has published a model NSA Notice with instructions on its proper use. While facilities and providers are not required to use the model NSA Notice, HHS considers its use in a manner consistent with the instructions to constitute good faith compliance with the relevant regulatory provision.

[3] This does not include patients who are covered by Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE, as these programs have other protections against surprise billing.

[4] For a complete explanation of the NSA’s disclosure and notice requirements, view PYA’s NSA Implementation Guide: Notice Requirements.

[5] 86 Fed. Reg. 36,591 (July 13, 2021). 

Executive Contacts

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