An employee at a mid-size manufacturing firm needs a routine hernia repair. She checks her insurance network, finds an in-network surgeon and hospital, and schedules the procedure. Everything goes smoothly. Three weeks later, a separate bill arrives from an out-of-network anesthesiologist who was never mentioned before the surgery. The charge is $2,800. Her plan pays a portion based on its out-of-network rate. The anesthesiologist’s billing office sends her the balance.
That balance-bill shock, the gap between what a plan pays and what the provider demands, was once a routine feature of American health care. A Kaiser Family Foundation analysis of 2017 claims found that about 1 in 6 patients received a surprise out-of-network bill after an emergency room visit or inpatient hospital stay. A 2020 study in JAMA put the figure for elective surgery at 1 in 5. The No Surprises Act (NSA), effective January 1, 2022, banned those bills in most emergency and certain non-emergency settings. An important safeguard, no question. But the smarter conversation about surprise bill protection is benefit design: eliminating the conditions that produce surprise bills in the first place.
The No Surprises Act Gives Employers a Floor, Not a Ceiling
The NSA bans balance billing and bases patient cost-sharing on a federally defined out-of-network rate. It protects patients from the worst financial shock. What it doesn’t do is stop the confusion, the paperwork, and the anxiety that come from even a single out-of-network touchpoint. In the first 34 months after the law took effect, CMS logged an estimated 14,576 complaints tied to No Surprises Act compliance. For an employer, each surprise-bill incident still means a distracted employee, a call to HR, and time spent untangling a charge nobody budgeted for.
The law created a backstop. It didn’t fix the architectural flaw that makes surprise bills possible: a primary health plan whose network is a patchwork of contracts, where any adjacent provider (the anesthesiologist, the radiologist, the assistant surgeon) can fall outside the employee’s coverage at the moment of care. As long as the employee’s first financial exposure is a plan that mixes in-network and out-of-network providers unpredictably, surprise bills will remain an administrative tax on both employee and employer.
Ground Ambulances Sit Outside the Law’s Protections
Air ambulance rides fall under the No Surprises Act. Ground ambulances don’t. Congress deferred rules for ground transport pending further study, leaving the most common way to reach an emergency room as the biggest remaining gap in surprise-bill protections. A Health Affairs study of 2013-2017 claims found a median surprise bill of $450 for ground transport, and a Peterson-KFF analysis found about half of emergency ground ambulance rides included an out-of-network charge.
This gap falls hardest on employers with self-funded plans. Washington extended its balance-billing protections to ground ambulances at the start of 2025, and by early 2026 people in 22 states had some protection. State laws can’t reach self-funded employer health plans, which cover most U.S. workers. The federal floor has a hole in the middle of the most common emergency.
No benefit design can steer a 911 dispatcher’s choice of ambulance. A first-use layer does something narrower and real: it removes the routine encounters where surprise billing is most common, so a patient never compounds an ambulance charge with more surprise bills downstream. Closing the ambulance gap itself is a legislative job. Until Congress acts, the employers who design surprise billing out of their routine care carry the least exposure to the gap.
The Structural Cause Is Fragmented Benefit Design
Surprise bills flourish when a health plan treats every service as a standalone transaction, adjudicated after the fact. The employee has no practical way to verify network status for every clinician who may step into the room. The primary plan, designed around cost-sharing and network contracting, has no mechanism to steer all care to pre-vetted, transparently priced providers before a claim occurs. The result is a billing event no one intended, resolved, if the NSA works, through after-the-fact arbitration between the plan and the provider, while the employee watches from the sidelines.
Employers who approach surprise bill protection only as a compliance exercise (update the SPD, post the required notice, train HR on the NSA’s independent dispute resolution process) are solving for the wrong problem. They’re building a better ambulance service at the bottom of the cliff. A structural solution starts with a first-use benefit layer that removes co-pays, aligns incentives around prevention and cost transparency, and gives employees a clear on-ramp to care that never generates a bill they didn’t authorize.
How a First-Use Benefit Design Prevents Surprise Bills
WellthCare™ is a Health-to-Wealth™ Benefit System that works alongside an employer’s existing ACA-compliant health plan and gets used first. Employees access $0-co-pay care for a broad set of services before their primary plan’s deductible or network rules ever engage. That set includes primary and preventive care, telehealth and virtual urgent care, diagnostics and labs, mental and behavioral health, care coordination, and medical bill review with cost transparency tools. Because WellthCare is structured as a self-insured supplemental plan with its own provider arrangements, the services it covers carry no out-of-network exposure for the member, so there are no surprise charges to fight. The plan’s cost management capability reviews bills to catch overcharges, and its care coordination guides employees toward appropriate, transparently priced care.
This first-use layer changes the logic of surprise bill protection from reactive to preventive. An employee who needs imaging, a specialist consult, or a minor urgent-care visit moves through the WellthCare system, with zero cost sharing, before their primary plan gets involved. That shift removes a large number of common encounters from the unpredictable network dynamics of the primary plan. It also builds engagement: employees who experience care with no bills and no co-pays become more likely to seek preventive services early, reducing the chance of a future acute event that lands them in an emergency room with a rotating team of billers.
The numbers back this pattern. WellthCare rewards employees with real, spendable dollars at the WellthCare Store™ for verified preventive health actions, scans, screenings, and assessments reviewed by licensed clinicians, creating a flywheel that replaces last-minute urgent care with planned, coordinated care. When the employee’s first stop for a health concern is transparent and zero-cost, the circumstances that generate the classic “anesthesiologist bill” never materialize for the services WellthCare covers. Employers typically see fewer surprise-bill disputes, less HR casework, and lower claims on the primary plan as utilization shifts into the first-use layer.
Compliance Is a Layer. Architecture Is the Strategy.
No employer should drop its NSA compliance program. But the employers who treat surprise bill protection as a benefit design goal, not just a legal checkbox, gain something the law alone can’t deliver: a workforce that trusts its health benefits because it never got burned. That trust shows up in retention surveys, in fewer employees delaying care, and in a steadier, more predictable benefits budget.
WellthCare inserts a structural guard against surprise bills for the services it covers (primary, preventive, urgent, diagnostic, telehealth, and behavioral health) by ensuring those services carry no cost sharing and no balance billing. It doesn’t replace major medical coverage. It sits in front, absorbing the kinds of routine and diagnostic encounters where surprise billing most often strikes. The hernia-repair anesthesiologist bill from the opening example still runs through the primary plan’s network; WellthCare doesn’t cover surgery. What it removes is everything around that event: the imaging, the labs, the specialist consults, and the follow-up care that would otherwise generate their own surprise charges. Over time, the employer gains a data-driven WellthCare Readiness Index™ (patent-pending) that shows exactly how much the primary plan’s claims are falling as utilization shifts to the first-use layer: math, not marketing.
When an employee can walk through a full year of health care, from preventive scans to urgent visits to ongoing chronic-condition support, without ever seeing a bill they didn’t agree to, “surprise bill protection” describes an outcome the benefit design delivers automatically. That’s the standard employers should aim for: a system where the surprise bill can’t arrive in the first place.
Ask your broker whether a WellthCare Plan fits your benefits strategy.
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This article is for general information only and is not legal, tax, or medical advice. Employers should consult their own advisors.