No Surprises Act Guide for Specialty Physicians and Facilities

If you handle billing for a specialty practice, you’ve probably found that general explanations of the No Surprises Act leave some of your questions unanswered. Your group may provide care at several hospitals, have its own agreements with insurers, and bill for services performed without ever meeting the patient. When a payment comes back low, those arrangements matter to how you can challenge it.

At Kotlar Cohen, our attorneys help healthcare providers determine which claims qualify for a payment dispute and prepare the records needed to pursue them. A No Surprises Act specialty physician attorney can review the circumstances behind an underpayment, including issues your billing staff may need help resolving before proceeding.

Below, you’ll find guidance for individual specialties, along with questions to work through when reviewing claims. To discuss your practice’s reimbursement concerns, call Kotlar Cohen at 856-751-7676.

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Reviewing a Claim Before Pursuing Payment

The No Surprises Act (NSA) protects patients from certain unexpected out-of-network bills and provides a payment dispute process for eligible claims. Before committing time to federal independent dispute resolution, or IDR, your practice needs to establish that the service falls within that process.

What the QPA Tells You

The qualifying payment amount (QPA) generally reflects an insurer’s median contracted rate for comparable services, adjusted for inflation under federal rules. It is a required consideration in federal IDR, although it does not automatically cap the amount a provider can receive.

When reviewing the payer’s QPA, compare it with the service billed, including modifiers and units. If the payer downcoded the claim, review its explanation to understand what changed.

The evidence supporting your payment offer should address the disputed service directly. For example, records documenting patient acuity or treatment complexity need an explanation of why those circumstances support the amount requested. Submitting the entire chart without identifying the relevant information can leave the reviewer to make that connection.

Our QPA and Economic Evidence guide explains how to evaluate the payer’s benchmark and prepare supporting evidence.

Provider and Facility Network Status

A hospital’s network participation does not necessarily extend to every physician working there. Confirm the facility’s status and your group’s status separately, even if your clinicians regularly treat patients at that location.

For covered non-emergency services, federal protections generally concern out-of-network care connected to a visit at a participating hospital, hospital outpatient department, or ambulatory surgical center. Emergency services follow different rules and can receive protection at out-of-network emergency facilities.

The professional and facility bills also need separate review. Although they arise from the same encounter, the available payment remedies may differ.

Notice and Consent

Check any notice-and-consent paperwork before relying on it. In limited circumstances, a patient can voluntarily waive federal balance billing protections after receiving the required notice, but a routine financial responsibility form does not meet those requirements.

Certain services cannot use the exception when federal protections apply. These include specified ancillary services such as anesthesiology, pathology, radiology, and neonatology. Emergency and post-stabilization services carry additional restrictions.

The Department of Labor’s explanation of notice and consent provides more detail about these limits.

Choosing the Appropriate Dispute Process

A claim review should establish:

• The patient’s plan type and relevant coverage.
• Where the service occurred and the network relationships involved.
• Whether a specified state law or All-Payer Model Agreement determines payment.
• Whether the disagreement concerns the payment amount or an adverse coverage determination.
• The payment or denial date and applicable deadlines.

Federal IDR addresses payment amounts for eligible services. If the issue is an adverse benefit determination, the applicable claims and appeals process is the appropriate route. Medicare and Medicaid reimbursement disputes also follow separate systems.

Our IDR Process Guide covers the steps from open negotiation through arbitration.

How Reimbursement Issues Differ by Specialty

The sections below explain where a claim review may need closer attention. A specialty’s inclusion does not mean that all of its services qualify for federal IDR.

ER Physician Groups

For an ER group handling a high volume of claims, keeping payment notices and deadlines connected to the right encounters can take considerable staff time. The clinical records need the same attention, particularly documentation of the symptoms that brought the patient to the emergency department.

Emergency status cannot be determined solely from the final diagnosis code. Preserve the circumstances recorded at presentation, and review the group’s professional claims separately from hospital charges.

Anesthesiology

Anesthesia groups often bill for care at facilities that participate in a patient’s plan even when the group itself does not. When the services are protected, anesthesia’s ancillary classification prevents notice and consent from removing those protections.

The reimbursement argument should account for the anesthesia work performed. Time, units, modifiers, and the payer’s calculation may all need review, rather than relying on a description of the underlying surgery to explain the payment request.

Orthopedic Trauma

Ortho trauma claims usually begin in the ER, so the emergency rules apply even if the surgeon and hospital are both out-of-network. The reimbursement fight is often over whether a follow-up or staged procedure still counts as emergency care. Keep the ED record with the operative notes, and check the payer’s QPA against every code billed, especially when several procedures happened in one session.

Emergency Plastics and Wound Closures

Repair codes depend on wound length, location, and complexity, so payers tend to pay the simple-repair rate or fold the closure into the ED visit. The chart needs the size, depth, contamination, and layers closed, written at the time of treatment. That detail is hard to reconstruct months later.

Neurosurgery

Check the setting first. A call to the ED for trauma or a bleed is emergency care. A scheduled spine surgery may involve a signed notice and consent, which can remove the NSA claim entirely. Where protections apply, the assistant surgeon bills separately and needs its own review.

General Orthopedics

Joint replacements and other planned procedures raise the notice-and-consent question before anything about payment. If a valid form was signed, the NSA likely doesn’t apply to the surgeon’s claim. If not, the surgeon, assistant, implants, and facility are all billed separately, and each claim gets its own review.

Air Ambulance

Air ambulance payment disputes involve details that do not appear in an ordinary hospital claim, including aircraft capabilities and pickup location. Records of patient acuity and crew training may also be relevant to the submission.

Before pursuing arbitration, account for both the administrative fee and the separate certified IDR entity fee. The CMS fee notices provide the current information providers should consult when budgeting for a dispute.

Ambulatory Surgery Centers

An ASC’s facility fee should be evaluated separately from the physicians’ professional fees. An in-network center’s disagreement over a contracted payment generally is not a federal IDR claim, even when an out-of-network physician involved in the encounter may have a different remedy.

Non-emergency care at an out-of-network ASC generally falls outside federal surprise billing protections. For the center’s own payment dispute, begin with the participation agreement and any applicable state remedies.

Radiology

A radiology claim may cover the imaging study, the interpretation, or both. Identify the component being disputed and how it relates to the patient’s visit before assessing eligibility.

For example, diagnostic work associated with a qualifying hospital encounter may raise different NSA issues from imaging performed through a standalone office appointment. The claim file should make that relationship clear rather than leave the treatment setting unexplained.

Pathology

Pathology groups may need information beyond their own reports to establish how a service falls within the NSA. Ordering records and details about the facility encounter can help connect the specimen to the patient’s care.

When federal protections apply, pathology’s ancillary status prevents the use of notice and consent to waive them. A generic consent form therefore cannot serve as the basis for transferring the disputed balance to the patient.

Hospitalist Groups

A hospitalist group may have a different network relationship with the payer than the hospital where its physicians work. Confirm both when reviewing an underpayment.

For protected non-emergency services, hospitalists cannot use the notice-and-consent exception. Admission records and service dates help establish the care involved, while documentation of each clinician’s work distinguishes the group’s professional claim from hospital charges and services billed by other specialists.

Surgical Assistants

The surgical assistant’s claim requires its own analysis, regardless of what the primary surgeon received. Review the assistant’s participation status, modifiers, and documented work in the procedure.

Assistant surgeons are an identified ancillary category under the federal rules. Supporting records should explain the assistant’s role in the protected encounter, including information that may not be apparent from the primary surgeon’s claim alone.

Independent Laboratories

An independent laboratory may perform testing without having ready access to the details of the patient’s facility visit. Obtaining those details can be necessary to determine whether federal IDR is available.

The laboratory itself is not automatically a qualifying facility under the non-emergency provisions. However, testing connected to a qualifying participating facility visit can fall within the rules even when performed elsewhere. Follow the specimen back to the source encounter before deciding how to pursue the claim.

Neonatal Intensive Care

Neonatal intensive care records can be extensive, so a payment submission should identify the professional services under dispute and the documentation that supports them. Hospital charges require separate consideration.

Neonatology falls within the ancillary restrictions. The infant’s condition and treatment needs may be relevant to a payment offer, but high acuity alone does not establish eligibility for federal IDR or guarantee a particular reimbursement amount.

Cardiology

A cardiology group may bill for office appointments, inpatient consultations, and emergency interventions. Screening those claims by setting and service helps avoid pursuing them all through the same process.

Determine the service’s relationship to emergency care or a qualifying facility visit first. If the claim is eligible, review the procedure and clinical records for evidence relevant to the payment request.

Orthopedic Surgery

Orthopedic surgery can generate separate bills for the surgeon, assistant, implants, and facility. Each claim needs review according to the service and billing entity involved.

An emergency operation differs from an elective procedure involving valid notice and consent. Implant expenses also require care in the analysis because the expense alone does not make a claim eligible for federal IDR.

Neurology

The setting of a neurological evaluation can affect how the NSA applies. A hospital consultation or emergency evaluation may raise questions that do not arise during an office visit.

For eligible claims, explain the work the clinician performed and why any relevant treatment complexity or qualifications support the offer. A diagnosis may help describe the patient’s condition without fully explaining the professional services being disputed.

OB/GYN

Delivery claims deserve review of the circumstances surrounding the particular service. Scheduled care, emergency evaluation, and unforeseen complications should not be treated as interchangeable for eligibility purposes.

One hospitalization may also produce obstetric, anesthesia, neonatal, and facility charges. Each provider may need different supporting records, even though the services formed part of the same course of care.

DME Providers

A prescription or hospital discharge order does not, by itself, make a durable medical equipment claim eligible for federal IDR. Review the billed item, coverage, and applicable law before choosing a dispute process.

For standalone equipment claims, a payer appeal or another remedy may be the appropriate way to address the payment. The connection to a hospital stay should not substitute for reviewing the equipment claim itself.

Ground Ambulance

Ground ambulance services generally fall outside federal NSA surprise billing protections. State law may provide another protection or payment dispute process, depending on the jurisdiction and the patient’s plan.

CMS’s medical billing guidance explains the distinction. Providers should not assume that the federal rules for air ambulance claims also apply to ground transportation.

Behavioral Health

For behavioral health practices, identifying the nature of the disagreement helps determine what to do next. Underpayment for protected care, a coverage denial, and a potential mental health parity violation can require different responses.

Emergency behavioral health care can receive NSA protections, while routine office treatment generally does not fall within the same federal facility-based framework. Review the service and the payer’s explanation together.

Multi-Specialty Groups

A shared billing department can coordinate deadlines and payer review across a group, but it still needs to preserve the information specific to each specialty and claim.

Before combining disputes, check the billing entities, legal eligibility, and applicable batching rules. Common ownership does not establish that claims belong in the same filing, and a shared submission still needs the evidence appropriate to the services involved.

Concierge Practices

Membership arrangements should be reviewed separately from insured clinical services. Operating a concierge practice does not automatically remove NSA obligations that would otherwise apply.

For uninsured patients or those choosing not to use insurance, good faith estimates and the separate patient-provider dispute process may be more relevant than an insurer payment dispute. Identify which charges and services are at issue before deciding how the rules apply.

Dialysis Centers

A standalone dialysis center is not automatically a qualifying facility under the federal non-emergency provisions. Hospital-based dialysis needs its own assessment rather than an assumption that all dialysis claims follow the same rules.

Payer information is especially important for practices handling both Medicare and commercial claims. Keep those reimbursement systems distinct when evaluating a disputed payment.

Working With Kotlar Cohen on Underpaid Claims

Your billing team may have already spent time reviewing a payment and contacting the insurer before seeking legal help. Bringing those records to the initial review allows the attorney to see what has happened and identify any approaching deadlines.

Kotlar Cohen represents healthcare providers in NSA reimbursement disputes. Founding partners Adam Kotlar and Justin Cohen co-chair the firm’s No Surprises Act practice, overseeing work that includes eligibility analysis, negotiation, and arbitration submissions.

The firm helps practices:

• Determine whether a claim belongs in federal IDR, a state payment process, or another review procedure.
• Establish relevant dates and track negotiation and filing requirements.
• Organize clinical and reimbursement records for the disputed service.
• Prepare a payment offer supported by permitted considerations.

Useful records include representative claim forms, remittance advice, payment or denial notices, network information, QPA disclosures, and negotiation correspondence. Together, these help explain the reimbursement issue and the steps already taken to resolve it.

Learn more about Kotlar Cohen’s No Surprises Act arbitration representation.