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The health care system in the United States, often known for its technological innovation and advancements, contains a heavy paradox: the same structure that delivers life-saving care can also impose substantial financial burdens on patients. This analysis explores the anatomy of surprise billing and balance billing, practices that can generate unexpected medical expenses for individuals, with a focus on regulatory gaps. We examine both federal and state regulatory approaches. A review of the No Surprises Act (NSA) and state laws indicates consumers may face challenges in understanding the scope of their protections, as the NSA may apply even in states with existing surprise billing laws and may only apply to specific individuals or billing occurrences. Through a comparative analysis of state policies, this study documents variation in regulatory approaches, including differences in robustness of consumer protections and design of arbitration mechanisms used to address out-of-network billing disputes. The analysis further indicates that arbitration models vary across states and may be linked to differing payment outcomes, with potential implications for insurance premiums and health care costs. These considerations situate the study within the broader public policy literature on consumer protections.