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Cracking the NSA: What Out-of-Network Surgeons Really Need to Know

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The No Surprises Act (NSA) has fundamentally reshaped how out-of-network providers deliver care, bill patients, and recover revenue. While many still assume it applies only to emergency services, the reality is that it touches nearly every surgical encounter. Too often viewed as just another layer of regulation, the NSA is far more than a compliance checklist — it directly affects reimbursement, collections, payer disputes, and even patient relationships. Forward-thinking practices recognize that mastering NSA compliance isn’t just about avoiding penalties; it’s about optimizing reimbursement, creating new growth opportunities, and strengthening leverage with insurers. At CH Revenue Management Solutions, we’ve seen how a strategic approach to NSA compliance helps providers shift the narrative from lost revenue to greater financial control.

Here are four strategies every provider should know:

1. The Misconception: “NSA Only Applies to Emergencies”

      Far too many practices dismiss the NSA as an “ER-only law.” That’s simply not true.

      • The NSA applies to non-emergency services performed at in-network hospitals or ambulatory surgical centers.
      • It also affects post-stabilization services and, in some states, extends even further through local balance billing laws.

      For surgeons, this means that nearly every procedure could be impacted.

      2. Understanding NSA Balance Billing Rules for Emergency and Non-Emergency Scenarios

      The NSA restricts balance billing in both emergency and many non-emergency settings:

      • Emergency services: Patients treated in emergency situations cannot be balance billed beyond in-network cost-sharing amounts, even if the provider is out-of-network.
      • Non-emergency services: At in-network hospitals or ambulatory surgical centers, out-of-network providers are also prohibited from balance billing unless the patient has received and signed proper Notice and Consent.

      Why it matters: Many practices mistakenly believe the NSA applies only to ER care. In reality, it extends across surgical and outpatient encounters, meaning almost every claim needs a compliance check.

      3. Integrating the Notice and Consent Process to Fit with Your Business Model

      The Notice and Consent (N&C) process is one of the most misunderstood — and underutilized — aspects of the No Surprises Act (NSA).

      • If your out-of-network practice wants to balance bill patients, N&C must be completed exactly as the regulations require. Any misstep can expose you to penalties for violating the NSA.
      • If your practice chooses not to balance bill patients, you can skip the N&C process, limit the patient’s responsibility to in-network cost-sharing, and use the NSA Independent Dispute Resolution (IDR) process to seek fair reimbursement — with an independent third party, not the insurer, deciding the outcome over 86% of the times in favor of the provider according to CMS data.

      Why it matters: Properly incorporating N&C into your workflows preserves flexibility in how you bill, protects your compliance posture, and ensures your business model remains financially sustainable under the NSA.

      4. Developing Airtight Compliance Systems to Prevent Revenue Loss and Avoid Penalties

      The complexity of the NSA demands more than ad-hoc fixes. To succeed, providers must embed compliance into their revenue cycle:

      • Track every encounter carefully to identify where NSA rules apply. Missing applicability triggers can lead to underpayments you can’t dispute, forced write-offs, and regulatory penalties. Robust tracking systems protect your practice by flagging encounters at risk.
      • Standardize the Notice and Consent (N&C) process to protect financial stability. Every form must be executed precisely within federal and state requirements to preserve the right to balance bill. If balance billing isn’t pursued, providers should use the Independent Dispute Resolution (IDR) process, where recent CMS data shows providers prevail in over 86% of disputes. Standardization reduces variability, ensures compliance, and creates leverage with payors.
      • Build guardrails into internal processes and strengthen documentation through staff education. Common failures — such as missing IDR filing deadlines and incorrectly billing patients  — can expose practices to penalties and lost revenue. Training staff to follow consistent procedures, while maintaining airtight records of billing practices, N&C forms, and cost-sharing disclosures, ensures audit readiness, minimizes disputes, and provides the evidence needed to substantiate claims during IDR.

      Why it matters: A proactive compliance system doesn’t just keep you penalty-free — it ensures you capture every dollar your practice is entitled to under the law.

      The No Surprises Act is here to stay — and for out-of-network surgeons, it will either erode your revenue or become the framework for financial strength and growth. The difference lies in how you respond. At CHRMS, we partner with independent surgeons to build airtight compliance systems, master the NSA dispute process, and turn underpayments into recovered revenue — before they compromise your bottom line. With the right strategy, the NSA isn’t a burden. It’s your leverage.

      This is the first installment in our five-part series on the No Surprises Act for out-of-network surgeons. In Part 2, we will explore the NSA Independent Dispute Resolution process in detail, showing you how to use it as a powerful tool to challenge underpayments and secure the reimbursements you deserve.

      If you want to safeguard your revenue and uncover where you may already be losing money, contact CHRMS today for a complimentary NSA compliance review.

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