Trying to Stop Surprise Medical Bills Created a Bigger Barrier

The paradox of the No Surprises Act, and where it stands in 2026

Written August 14, 2026 | Sources: KFF Health News, McDermott+, CoveredUSA, TechTimes

Have you heard about someone going to an emergency room in the United States and receiving a bill for thousands of dollars afterward? The federal No Surprises Act (NSA), introduced in 2022, was meant to solve exactly that problem. Four years after it took effect, though, the cost burden patients actually feel has grown rather than shrunk. Here is why, along with the latest 2026 data.

1. What the law was meant to prevent

The NSA was designed to stop the “surprise medical bill” — a large, unexpected charge from an out-of-network provider the patient never chose, such as an anesthesiologist, radiologist or pathologist. It protects three things in particular:

• Emergency care: when you use an out-of-network emergency room, your cost sharing is capped at the in-network rate
• Out-of-network services at an in-network facility: balance billing is prohibited for the anesthesiologist or radiologist you encounter during a procedure at an in-network hospital
• Air ambulance: air ambulance costs, previously the single largest loophole, are also capped at the in-network rate

2. The gaps — three decisive loopholes

① The waiver loophole

In certain situations, a hospital can ask a patient to sign a “Surprise Billing Protection Form” — a waiver of their rights. The moment that single page is signed, the federal protection disappears and the full out-of-network cost becomes the patient’s responsibility. Worse, that cost may not count toward the plan’s annual deductible or out-of-pocket maximum.

Government estimates of how often patients end up signing:

• Post-stabilization care: 50% of consumers ultimately sign
• Non-emergency care in network: 95% of consumers ultimately sign

② The blind spots the law does not reach

• Ground ambulance: excluded from NSA regulation entirely. Only 22 states have their own protective law — patients in the other 28 states are unprotected
• Non-emergency out-of-network facilities: care received in non-emergency settings such as general clinics, birthing centers, hospices, nursing homes and addiction treatment facilities is not covered by NSA protections
• Short-term and pre-ACA plans: people enrolled in grandfathered plans purchased before the ACA took effect, and in short-term plans, are outside the scope of protection

③ The burden of proof falls on the patient

Responsibility for correcting an improper bill rests entirely on the patient noticing it and filing an appeal. But the appeal rate among Marketplace enrollees is under 0.2% — so low that the protection is effectively not functioning at all.

3. NSA enforcement in 2026 — still unfinished

The latest enforcement picture, per McDermott+ analysis:

• IDR operating rules incomplete: the Independent Dispute Resolution operating rules proposed in November 2023 remained unfinalized into early 2026 in the aftermath of the government shutdown. A further 90–180 day grace period is possible after the final rule is published
• QPA enforcement discretion extended: the method for calculating the Qualifying Payment Amount — the central benchmark between insurers and providers — has been extended under enforcement discretion until August 1, 2026 because of ongoing litigation (the Texas Medical Association’s third lawsuit), which in practice lets insurers apply their own calculation
• Four provisions still not in force: the requirement to provide cost estimates on insurance ID cards, the Advanced Explanation of Benefits (AEOB), provider directory accuracy standards, and continuity of care protections

4. The balloon effect — the rise of the prepayment barrier

When the NSA cracked down on billing after care, hospitals immediately changed tactics. To eliminate the risk of not being paid afterward, they began collecting money before care. The 2026 data shows the shift in numbers.

① Soaring deductibles, falling collection rates

Metric	Figure	Note
Average deductible, employer-provided family plan	$3,762 / person
Average ACA Marketplace deductible (2026)	$3,786	up 37% year over year
Actual patient collection rate (2025)	42.4%	down from 45.1% in 2024
Hospital net loss on uncollected bills (2025)	$48 billion	up 25% from $38.6 billion in 2024
Share collecting prepayment before care (2026)	~25%	rising from ~15% in 2015

② Even top-tier hospitals now demand deposits up front

• Mayo Clinic: mandatory pre-service deposit for out-of-network cases
• Johns Hopkins Medicine: explicit policy of “collecting the full billed amount before services are provided” for non-emergency care
• MD Anderson Cancer Center: initial deposit billed according to cancer type

A real case — Thomas Zordani v. Mayo Clinic (2025–2026). Mr. Zordani visited Mayo for a neurosurgical consultation. His insurer’s portal showed an expected out-of-pocket cost of just $565, but Mayo demanded a $5,000 deposit before the appointment. When he refused to pay, the appointment was cancelled on the spot. He subsequently filed for arbitration alleging a violation of Arizona consumer protection law, and in September 2025 the arbitrator ruled that Mayo was liable for $47,500 in damages and attorney’s fees.

Outcomes like this are extremely rare, however. Most patients have no option but to pay the deposit or give up on treatment.

5. The overpayment refund problem — another trap

Prepayment carries a second trap. After a hospital collects a deposit based on an expected deductible, another provider’s claim may be applied to that deductible first during actual claims processing — leaving the patient unable to get the overpaid deposit back. The federal government has set no separate refund deadline, so patients are left waiting indefinitely.

State-level responses as of 2026:

• Arizona (January 2026): SimonMed Imaging consent judgment — a $50,000 penalty plus $20,000 in restitution, a mandatory average refund period within 60 days, and required disclosure of a “tokenization option” (billing after claims processing)
• Florida (2026): a 30-day refund deadline for providers written into law
• Maryland: prohibits requiring pre-service deposits from patients who qualify for financial assistance

The problem is that there is no federal standard. Three states have protections in place; patients in the other 47 have almost no legal right to a refund of an overpayment.

6. The double barrier patients face — a structural view

Ultimately, the reason the medical costs patients feel keep rising is not simply that the price of treatment went up. Three structural factors are interlocking:

• Step 1 — High deductibles. An average of $3,762 per family member. The patient’s own share rises at the source
• Step 2 — NSA loopholes and workarounds. Waiver forms and unimplemented provisions neutralize the law’s protection
• Step 3 — The prepayment barrier. Hospitals shift collection risk onto the patient, demanding thousands of dollars before care

Patients are now in a position where they must come up with thousands of dollars as an up-front deposit before treatment even begins, or be denied the opportunity for treatment at all. The NSA may have blocked some portion of the “surprise bill after the fact,” but it has produced a paradox — a new and higher barrier to entry beforehand, which increases both the real cost felt by patients and the distress that comes with it.

7. What patients can do right now

• Check the network before you book: confirm on your insurer’s portal that both the facility and the treating physician are in network
• Request an itemized estimate: ask in writing for the basis and method used to calculate the deposit — hospitals are required to provide a Good Faith Estimate
• Review before signing any waiver: if you are pressured to sign a form waiving NSA protections, confirm whether you can refuse before you sign
• Secure your appeal channel: if you spot something wrong with a bill, appeal to both the insurer and the provider — the current usage rate is under 0.2%, but it is effective
• Report to the state attorney general: improper deposit demands and delayed refunds can be reported to your state’s consumer protection division and attorney general’s office

In conclusion

Regulation does not always eliminate a problem — sometimes it relocates it. The NSA was regarded as a landmark patient protection law when it was introduced in 2022, yet as of 2026 even its enforcement rules are not finished. While the waiver loophole, the ground ambulance blind spot and the QPA litigation continue, hospitals have shifted the risk onto patients through a new collection strategy: the up-front deposit. This is where the heart of the American medical cost problem lies.

Sources

• KFF Health News — Hospital Prepayment Requirements Add New Wrinkles to Patients’ Financial Responsibility (August 2026)
• McDermott+ — No Surprises Act Implementation in 2026: The Regulatory ‘To-Do’ List (2026)
• TechTimes — Hospitals Demand Cash Before Care: Insured Patients Have Almost No Legal Recourse (August 12, 2026)
• CoveredUSA — No Surprises Act 2026: What’s Still Protected and What’s Not (2026)
• NBC News / CBS News / Yahoo News — Hospitals Are Asking Insured Patients to Prepay for Treatment (2026)
• CMS.gov — No Surprises Act Overview of Rules & Fact Sheets

This article is provided for informational purposes. For individual medical and financial decisions, please consult a professional.