Understanding No Surprises Act Good Faith Estimates for Healthcare Providers

As a healthcare provider, it's essential to understand the No Surprises Act's Good Faith Estimates. This law requires providers to give patients a detailed estimate of expected charges for scheduled services.

Good Faith Estimates must be provided at least three business days before a non-emergency item or service. This gives patients time to review and understand the costs involved.

Providers must include certain details in the Good Faith Estimate, such as the expected charges for each item or service, any applicable discounts, and the name and address of the provider.

Healthcare providers and facilities, such as hospitals, outpatient clinics, and labs, are required to provide Good Faith Estimates.

Physicians, air ambulance services, and imaging centers are also required to provide GFEs.

Ancillary providers, like dentists, chiropractors, and physical therapists, must also provide Good Faith Estimates.

Healthcare providers aren't required to provide a GFE to those covered by Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, and Tricare.

The No Surprises Act requires providers to post a notice about Good Faith Estimates (GFEs) for uninsured and self-pay patients on their websites and in-person locations. This notice should be easily accessible and visible to patients.

The notice should be accompanied by a separate required notice about surprise billing for out-of-network services. Both notices can be found in the downloadable resource package from HHS, which includes model notices for providers' use.

The American Hospital Association (AHA) estimates that it takes 10 to 15 minutes to make a single GFE. To comply with the requirement, facilities need to establish a clear and repeatable procedure for completing and sending GFEs on time.

The timing of delivery is a crucial aspect of providing a Good Faith Estimate (GFE). The No Surprises Act stipulates that GFEs must be sent according to a strict schedule.

If an appointment or service is scheduled three to nine business days in advance, the GFE must be sent within one business day after the date of scheduling. The clock starts at the point of scheduling, and deadlines work forward from there.

The American Hospital Association estimates that it takes 10 to 15 minutes to make a single GFE. Facilities need to make operational and workflow changes to comply with the requirement, not just to send GFEs out, but also to monitor compliance systemwide.

Here's a summary of the timing guidelines:

Any anticipated change in a GFE must be provided to the patient no later than one business day before the item or service is scheduled to be furnished.

A GFE informational notice developed by HHS must be prominently displayed on a provider's website, in their office or facility, and on-site where scheduling or questions about the cost of items or services may occur.

Providers and facilities must also provide information about the availability of a GFE to uninsured and self-pay patients when scheduling an item or service or when questions about the cost of items or services occur.

A GFE template developed by HHS is available for providers to use.

A GFE must be available in accessible formats and in the language(s) spoken by individual(s) considering or scheduling items or services.

A good faith estimate is a crucial document that mental health professionals must provide to their patients. It's a written estimate of the costs associated with the patient's treatment, and it must be delivered in written form, either on paper or electronically, and must follow a verbal notice.

To create a good faith estimate, you'll want to include the patient's name and date of birth. This is a standard requirement, and it's essential to get it right.

A clear and easy-to-understand description of the primary item or service is also necessary. This should include the scheduled date of the primary item or service, if applicable.

The good faith estimate must also include an itemized list of items or services as part of the treatment, grouped by each convening and co-provider or facility, to be provided during a defined period of care. This list should include the diagnosis, expected service codes, and expected charges associated with each listed item or service.

You'll also need to include the name, National Provider Identifier (NPI), and Tax Identification Number (TIN) of providers involved in the treatment. This ensures transparency and accountability.

Here's a summary of the essential items to include in a good faith estimate:

Under the No Surprises Act, healthcare providers are required to give you a good faith estimate (GFE) of the expected charge for a service. This is the amount they would charge a cash-paying customer, or an uninsured patient.

The expected charge is inclusive of any discounts or adjustments that might be applied. This means you'll get a clear picture of what you'll be responsible for paying upfront.

If there's no expected charge, such as when the provider anticipates a $0 price, GFEs will still be required. There are no minimum qualifying payment amounts, so you'll still get a good faith estimate of the costs involved.

Here's a breakdown of what you can expect from the good faith estimate:

This information will help you prepare for your medical expenses and avoid surprise bills.

To comply with the No Surprises Act, providers must post the Good Faith Estimate (GFE) notice on their websites and in-person locations. This notice should be the same model notice developed by HHS.

Providers also need to post a separate notice about surprise billing for out-of-network services, which is another model notice developed by HHS. This is in addition to the GFE notice.

Making workflow adjustments can help mitigate risks associated with the GFE requirements, such as sending the estimate too late.

Posting the Notice is a crucial step in complying with the No Surprises Act. You should post the required No Surprises Act GFE notice for uninsured and self-pay patients on your website and in-person locations.

The notice should be easily accessible and noticeable, just like a HIPAA Notice of Privacy Practices. HHS has developed a model notice that you can download and use.

In addition to the GFE notice, you must also post a separate notice about surprise billing for out-of-network services. HHS has developed a model notice for this as well.

As a provider, you must prominently display information about the availability of a GFE on your website, in your office or facility, and on-site where scheduling or questions about the cost of items or services may occur. This includes providing the notice in accessible formats and in the language(s) spoken by individual(s) considering or scheduling items or services.

You can find a GFE informational notice developed by HHS on their website. It's essential to make this notice easily accessible to all patients, including those who are uninsured or self-pay.

Making workflow adjustments is a crucial step in preparing for GFE requirements. This can help mitigate risks, such as sending the GFE too late.

Sending the GFE too late is a significant risk, and adjustments can help prevent this from happening. Consider how your organization currently handles GFE submissions and identify areas for improvement.

Adjustments can also help mitigate other risks associated with GFE requirements. By streamlining your workflow, you can ensure compliance and avoid costly delays.

When you need unscheduled services, you're protected from surprise bills in certain situations. If you're treated by an out-of-network doctor at an in-network hospital or ambulatory surgical center, you're protected from surprise bills.

For unscheduled services, you're only responsible for your in-network cost-sharing. This means you won't be hit with surprise bills for services you didn't plan or schedule.

If you're an uninsured patient, or if you're insured but don't plan to file a claim, healthcare providers must give you a good faith estimate of their expected charges before you receive the services. This estimate should be provided within a certain timeframe, depending on how far in advance you scheduled the service.

Here's a breakdown of when you can expect to receive a good faith estimate:

The good faith estimate should include a description of the service, a list of other services that are reasonably expected to be provided, the diagnosis and expected service codes, and the expected charges for the services.

Internal controls are crucial for standardizing GFE workflows and preventing variations. Establishing internal controls and policies around generating the GFE and monitoring compliance can make a big difference.

To ensure that internal controls are effective, use reporting and alerting tools at the point of scheduling to alert the scheduler or other staff that a GFE is required, as well as a form to generate the GFE. This can facilitate workflows while mitigating variation.

Staff training is also essential, especially when workflows adjust. Training gaps can drive variation and noncompliance risk, so it's vital to ensure that trainings and tools get equally distributed across the workforce.

Internal controls are essential for standardizing workflows, especially when generating GFEs. Variations will inevitably occur if internal controls aren't in place.

Establishing policies around generating the GFE and monitoring compliance is crucial. This includes using reporting and alerting tools to notify staff when a GFE is required.

Developing tools that assist in preparing for routine services can significantly facilitate workflows.

Staff training is crucial to ensure compliance and consistency in your organization. As workflows adjust, training gaps can further drive variation and noncompliance risk.

To address this, trainings and tools should be equally distributed across the workforce, covering various areas such as generating the GFE and communicating about it to patients.

Training should be dynamic, adapting with workflow modifications and regulation changes to stay relevant and effective.

The No Surprises Act's scope extends far beyond what you might expect, especially when it comes to Good Faith Estimates (GFEs). As the law is nuanced, it's essential to understand the scenarios that emphasize its reach.

Scenarios to watch for include situations where the law's scope extends, emphasizing just how far it goes. This highlights the complexity of the law and the need for careful consideration.

A range of costs can sometimes be acceptable for the Good Faith Estimate (GFE), but it's essential to capture all charges. The Centers for Medicare and Medicaid Services (CMS) recommends this approach.

To avoid a compliance risk, try not to make the range too big. For example, a psychiatrist might recommend between 10 and 25 sessions at 50 minutes each within a year.

Identify factors that could result in the lower or higher ends of the range. This will help you provide a more accurate estimate. Factors might include the patient's specific needs or the complexity of the case.

For highly complex cases, communicate with the patient to understand their preferences. This can help narrow the scope of the applicable range.

Here's an example of how to approach ranges: a psychiatrist might recommend between 10 and 25 sessions at 50 minutes each within a year, listing a charge at a given rate per session and what that is expected to total at the end of the year.

The goal is to provide a comprehensive estimate that reflects the anticipated costs based on the services rendered.

Co-providers and co-facilities will need to collaborate to determine what should go into the GFE, especially when comprehensive care involves multiple providers and facilities.

Starting January 1, 2023, the convening provider will have to work with co-providers and co-facilities to create an accurate GFE.

Collaborating with co-providers and co-facilities now will help prepare for the Phase 2 regulations in January 2023.

Having discussions to get familiar with the components that contribute to an accurate GFE is a good idea.

Establishing rules of the road prior to the due date can help ensure turnaround times, staff training, and controls are in place.

Consider implementing and testing the collaboration process before the due date to avoid any last-minute surprises.

Collaborations and Scenarios are complex and can be tricky to navigate. The No Surprises Act has nuanced rules around certain aspects, including GFEs.

The law's scope extends far beyond what you might initially think. The rules around GFEs are particularly intricate. The law's scope extends to various scenarios, emphasizing its far-reaching impact.

As a result, it's essential to be aware of these scenarios to avoid any potential issues. The law's scope is vast, and its application is multifaceted.

If you're a healthcare professional, it's essential to understand how the No Surprises Act affects your practice. The act requires providers licensed to provide scheduled health care services to send a GFE to self-paying or uninsured patients who schedule an item or service.

As a dentist, physical therapist, or chiropractor, you need to be aware of this requirement, especially when it comes to providing estimates to self-pay or uninsured patients shopping for services. If you're asked to provide an estimate, you're required to send a GFE.

You should also be prepared to send a GFE to self-paying or uninsured patients who schedule an item or service. This is a crucial step in complying with the No Surprises Act.

If the scope or provider changes, it can be a bit of a challenge to navigate. The good news is that providers must send a new Good Faith Estimate (GFE) within one business day before the scheduled item or service is rendered.

A change in provider requires the new provider to uphold the original GFE if the change occurs less than one business day before the scheduled item or service. This ensures that patients are protected and can plan accordingly.

Patients receiving non-emergency services from out-of-network providers in in-network facilities are protected from surprise bills.

In emergency situations, patients are shielded from surprise bills for services rendered by out-of-network providers, regardless of their network status.

The No Surprises Act provides a fair and transparent arbitration process for resolving billing disputes between insurers and healthcare providers.

If a patient is unsure about their insurance status, it's essential to ask directly to confirm their coverage.

Providers are responsible for knowing the patient's insurance status, so consider implementing changes to intake forms or scheduling scripts to confirm this information.

If a patient is insured, ask directly whether they intend to self-pay for services. This will help you determine if a Good Faith Estimate (GFE) is required.

You're protected from surprise bills when you're treated by an out-of-network doctor at an in-network hospital or ambulatory surgical center. These protections are increasing and will now include all providers, not just doctors.

You're also protected from surprise bills when an in-network doctor refers you to an out-of-network provider. This includes services you get when you're in your doctor's office, when your doctor sends a sample taken from you to an out-of-network lab or pathologist, and for other health care services when a referral is required and you received a referral from your in-network doctor.

You're covered for emergency services in a hospital if you have a medical or behavioral condition and you need immediate medical treatment. You're protected from bills for out-of-network emergency services in a hospital, including inpatient care following emergency room treatment until you're discharged from the hospital.

These protections are increasing and will now include all providers, not just doctors, for emergency services in hospitals. You're only responsible for your in-network cost-sharing for these bills.

In some cases, you might get misinformation about a healthcare provider's network status from your health plan. This can happen if an out-of-network provider is listed as in-network in your health plan's online or hard copy provider directory.

If an out-of-network provider is wrongly listed as in-network in your health plan's online provider directory, you'll pay no more than your in-network cost-sharing for those services. This protection applies to both online and hard copy directories.

Your health plan might tell you in writing that a provider is in-network when they're not, or they might not tell you the network status of a particular provider in writing within one business day of your request.