Did you know that all physicians are affected by the No Surprises Act that went into effect January 1, 2022, even those physicians not subject to balance billing restrictions with hospital contracts? If you have glossed over articles or toolkits provided thinking they do not apply to you, think again!
Good Faith Estimates (GFEs):
While the big focus of the No Surprises Act was balance billing restrictions with insurance, the Act also provided new rules to help for patients who are uninsured or self-pay. The Act requires all physicians in all health care settings, including small and solo practices, to generate cost estimates, known as Good Faith Estimates (GFEs), when treating patients who are uninsured, self-pay, or commercially insured who chose not to use their benefits. In the near future, the intention of the Act is to eventually require physicians provide GFEs to insurance companies for insured patients.
GFEs for All Items and Services:
Physicians are required to provide a GFE under the rule for "items and services" defined as "all encounters, procedure, medical tests, ... provided or assessed in connection with the provision of health care." Services include those related to mental health and substance use disorders.
The estimate must be in “good faith,” meaning that it should not be generic if there are foreseeable extra costs due to complications. However, the GFE does not have to provide a worst-case scenario. A GFE would also not be provided for emergency services. CMS created a template for the information that should be included [pdf] and lists the elements to include if you want to create your own form [pdf].
Notice of the availability of the GFE must be posted on the provider’s or facility’s website, at the office, and on- site. CMS has provided a model notice for physicians to post, and it should also be posted on a practices’ website (if one exists). CMS created a model notice you can use. [pdf]
How Do I Know if I Need to Provide a GFE?
Physician practices must ask your patients up front if they have health insurance, and if they intend to submit a claim to the insurance company for the service. You also must have a notice displayed in your office and on your website (if you have one) that a GFE of expected charges is available in writing and will be provided verbally when the service is scheduled.
What is the Timeline for Providing a GFE?
The federal Act is burdensome and creates uncertainty for physicians as they try and see patients quickly when treatment needs arise. The law requires a GFE be provided when an uninsured or self-pay patients schedules a procedure or request an estimate of costs. When a service has been scheduled, the GFE is to be provided not later than one business day after the date of scheduling if the service is scheduled at least three business days before the service, and within three business days of scheduling if the service is scheduled at least ten business days in advance. If a GFE is requested before the service is scheduled, the GFE is due within three business days. Once the service is scheduled, a new GFE must be provided.
What Happens if the GFE is wrong?
If the charges by a physician exceed the GFE by more than $400, the patient may dispute the charges under the No Surprises Act arbitration process. A physician cannot collect on the disputed bill while the dispute is pending, and must wait to receive.
I Treat Patients Elsewhere Too. Who is responsible for the GFE?
The facility scheduling the primary service is known as the "convening provider or facility" and is required to provide the GFE. The physician that provides services in conjunction with the "convening facility" must also provide this information to the facility. There are rules around how quickly this information must be provided to the convening facility when requested. While CMS encourages parties to work on this now, CMS has provided time until 2023 for the convening facility to gather the information and provide one GFE to the patient, rather than a patient receiving separate documents from each provider.
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