Navigating the No Surprises Act and Price Transparency: An Essential Guide for Compliance

Key Takeaways

• The No Surprises Act (NSA) and Price Transparency rules share a common goal of protecting patients from unexpected healthcare costs but differ significantly in scope and requirements.
• The No Surprises Act primarily focuses on protecting patients from balance billing and mandates Good Faith Estimates (GFEs) for uninsured or self-pay patients.
• Price Transparency rules require hospitals and payors to publicly disclose negotiated rates and make cost information accessible for consumers.
• Many organizations remain partially compliant due to confusion over reporting obligations, data posting formats, and lack of system integration.
• Understanding how to apply these provisions effectively can strengthen patient trust, reduce compliance risk, and protect organizational revenue.

The Evolving Landscape of Healthcare Transparency

Healthcare transparency has become a defining pillar of patient rights and revenue integrity. Two major regulatory forces—the No Surprises Act (NSA) and Hospital Price Transparency—have dramatically reshaped how healthcare organizations must communicate costs and handle patient billing.

Both were designed to bring clarity to an opaque pricing environment. However, their overlapping yet distinct mandates have created confusion across hospitals, physician practices, and revenue cycle management (RCM) teams. Many providers remain unaware of the depth of their disclosure responsibilities or underestimate the operational impact of noncompliance.

In 2025 and beyond, regulatory scrutiny is intensifying. The Centers for Medicare & Medicaid Services (CMS) has ramped up audits, publishing public compliance reports and imposing financial penalties on noncompliant entities. The need to understand and operationalize these rules has never been greater.

Understanding the No Surprises Act (NSA)

The No Surprises Act, effective January 1, 2022, was enacted to protect patients from unexpected medical bills resulting from out-of-network services—especially in emergencies or when treated by out-of-network clinicians at in-network facilities.

Key Requirements of the No Surprises Act

• Balance Billing Prohibition:
  Providers are prohibited from billing patients for amounts beyond in-network cost-sharing rates in covered scenarios.
• Good Faith Estimates (GFEs):
  Providers and facilities must furnish uninsured and self-pay patients with an itemized estimate of expected charges before services are rendered.
• Dispute Resolution Process:
  The NSA establishes an Independent Dispute Resolution (IDR) process to resolve payment disagreements between providers and insurers.
• Notice and Consent Rules:
  In limited non-emergency situations, patients may consent to out-of-network care if properly notified and agreeing to pay out-of-network costs.

Who Must Provide a Good Faith Estimate?

• All licensed healthcare providers and facilities treating uninsured or self-pay patients are required to issue GFEs upon request or when scheduling services.
• GFEs must include anticipated charges for primary and associated items/services, covering labs, imaging, anesthesia, and related components of care.
• The estimate must be clear, accessible, and provided within prescribed timeframes—typically within three business days of scheduling.

Failure to comply can trigger civil monetary penalties and expose organizations to patient complaints through CMS’s enforcement channels.

Understanding the Price Transparency Rule

The Hospital Price Transparency rule, effective January 1, 2021, requires hospitals and payors to make detailed cost information publicly available. This includes standard charges, cash prices, and all negotiated rates with payors—published in both machine-readable and consumer-friendly formats.

Key Disclosure Requirements

• Comprehensive Machine-Readable File (MRF):
  Hospitals must publish an MRF listing all standard charges—including gross charges, discounted cash prices, and negotiated rates—for all items and services.
• Consumer-Friendly Shoppable Services Display:
  At least 300 shoppable services (or all if fewer) must be displayed with easy-to-understand pricing and descriptions.
• Payor Transparency:
  Insurers are required to provide cost-sharing estimates and price comparison tools to empower patients to estimate their out-of-pocket costs.

Common Compliance Gaps

Despite multiple rounds of guidance, compliance rates remain low.

• Many hospitals post incomplete files or fail to include all negotiated rates.
• Inconsistencies in data formatting and accessibility hinder compliance.
• Some organizations struggle to integrate payer data, resulting in partial disclosures or outdated information.

CMS continues to increase enforcement, issuing fines that can exceed $2 million annually per hospital for persistent noncompliance.

Distinguishing Between the Two Regulations

While both regulations promote transparency, their intent and operational focus differ:

Understanding these differences allows healthcare leaders to allocate responsibilities effectively—often requiring collaboration between compliance, RCM, and IT teams.

Leveraging Price Transparency for Operational Advantage

While compliance is mandatory, transparency initiatives can also deliver strategic benefits. Hospitals and clinics can use published rate data to:

• Benchmark competitive pricing against peers to negotiate stronger payer contracts.
• Empower patients with upfront cost information, improving trust and satisfaction.
• Enhance financial forecasting by understanding payor patterns and reimbursement trends.
• Streamline RCM processes, integrating transparent pricing into digital tools like cost estimators and scheduling portals.

For clinics and ambulatory facilities, transparency data also helps align service pricing strategies, identify billing inefficiencies, and strengthen payer negotiation positions through data-driven insights.

Addressing Internal Inconsistencies

One of the challenges in applying both sets of regulations lies in their internal inconsistencies:

• The NSA’s Good Faith Estimate focuses on individualized cost prediction, while Price Transparency centers on aggregate rate publication—requiring different datasets and workflows.
• The timelines and data formats prescribed under each rule vary, creating duplication of effort.
• Some definitions—such as what qualifies as a “facility” or a “service package”—are interpreted differently under each regulation, causing compliance ambiguity.

Organizations must therefore build coordinated compliance frameworks that harmonize both rules—ensuring data accuracy, consistency, and workflow efficiency.

Building a Unified Compliance Strategy

Effective compliance depends on cross-functional collaboration and technological integration. Leading organizations adopt these best practices:

• Conduct Regular Compliance Audits:
  Assess posted data for accuracy, completeness, and timeliness.
• Centralize Rate Management:
  Use automated tools to synchronize rate files, contracts, and GFE templates.
• Train Staff Across Departments:
  Educate patient access, billing, and RCM staff on both rules’ requirements.
• Leverage Technology:
  Employ digital cost estimators, API integrations, and revenue analytics to automate data uploads and improve patient transparency.
• Engage Compliance Experts:
  Work with legal and RCM specialists to interpret updates, respond to audits, and maintain alignment with evolving CMS guidance.

Key Compliance Checklist

A practical compliance roadmap for healthcare organizations:

For the No Surprises Act (NSA):

• Provide Good Faith Estimates (GFEs) for all uninsured and self-pay patients.
• Include related items and services in the GFE (e.g., anesthesia, labs, imaging).
• Deliver estimates within 3 business days of scheduling or upon request.
• Ensure staff are trained on notice and consent requirements.
• Maintain records of all GFEs and patient notifications for audit readiness.

For Price Transparency:

• Publish a machine-readable file (MRF) with all standard and negotiated rates.
• Post a consumer-friendly display of at least 300 shoppable services.
• Verify that data is updated at least annually and remains easily accessible online.
• Coordinate with payors to confirm data accuracy and consistency.
• Conduct periodic internal audits to identify and correct gaps.

Following this checklist helps organizations stay compliant, avoid costly penalties, and demonstrate a commitment to transparency and patient-centered care.

The Bottom Line

Transparency isn’t just a regulatory mandate—it’s a powerful trust-building and risk mitigation strategy. By mastering the No Surprises Act and Price Transparency requirements, healthcare organizations can move beyond compliance to create a culture of openness, strengthen patient relationships, and safeguard revenue integrity.

Promoting Compliance Through Professional RCM Support

At Bristol Healthcare Services, we understand that navigating complex regulatory requirements—like the No Surprises Act and Price Transparency rules—can strain internal teams. Our Revenue Cycle Management and Compliance experts help healthcare organizations achieve end-to-end regulatory alignment through:

• Accurate Good Faith Estimate management
• Data integration and automation for price postings
• Ongoing monitoring to ensure continuous compliance
• Customized staff training to prevent costly errors

By partnering with Bristol Healthcare Services, providers can confidently meet compliance obligations, protect revenue, and deliver greater financial clarity to patients.

Let our experts simplify compliance—so you can focus on patient care!