In an attempt to create better understanding of the price of care prior to its provision, the NSA has created new requirements for good faith estimates (GFEs) that may affect surgeons. There are three separate circumstances under which a GFE might be required under the NSA:
- For out-of-network insured patients as part of "notice and consent" in non-emergency situations (applicable only to the services of that provider)
- For the insurance plan/issuer of an insured patient for purposes of an Advanced Explanation of Benefits (Advanced EoB) to patients from insurers (regulations pending).
- For uninsured and self-pay patients for non-emergency items and services, including all reasonably expected provider and facility charges associated with the scheduled item or service.
The GFE required in scenario one is the simplest, requiring only an estimate of charges that you will bill directly to an out-of-network patient as part of the "notice and consent" process in scenarios where patients may waive their No Surprises act balance billing protections.
The regulations implementing the GFE required for insured patients have been delayed until future rulemaking but are likely to take effect as early as January 2023.
Finally, in the case of uninsured and self-pay patients it is likely that surgeons could be deemed to be the "convening provider" and therefore responsible for not only providing an estimate of their own services, but also of all services commonly provided in conjunction with the procedure. The regulations define the term "convening provider" or "convening facility" to mean the provider or facility who receives the initial request for a good faith estimate from an uninsured or self-pay patient AND who is responsible for scheduling the primary item or service.
The convening provider is responsible for collecting estimates from "co-providers" and "co-facilities," that is any provider or facility other than the convening provider or facility that furnishes items or services that are customarily provided in conjunction with any primary item or service. For surgery this could be far reaching including hospital charges, anesthesia etc.
The uninsured and self-pay GFE is also more broadly applicable than the cost-sharing and balance billing protections because it is not limited to emergencies or out-of-network providers at in-network facilities. Any time an uninsured or self-pay patient makes a request or schedules care a GFE is required unless the item or service is scheduled to be furnished in under 3 days. It is also important to keep in mind that self-pay includes those who "do not seek to have a claim for such item or service submitted to (their) plan or coverage" i.e. patients choosing to pay out of pocket rather than submitting a claim to insurance.
CMS has provided a model GFE notice. Use of this specific document is not required, but it may be helpful in ensuring that your GFE contains all of the required information. The model GFE can be found here:
https://www.cms.gov/regulations-and-guidancelegislationpaperworkreductionactof1995pra-listing/cms-10791
Specific Requirements for uninsured or self-pay GFEs:
- Applicable to all items and services reasonably expected to be necessary with the scheduled or requested item or service
- The convening provider or facility must contact all applicable co-providers and co-facilities no later than 1 business day after the request for the good faith estimate is received or after the primary item or service is scheduled, and request submission of expected charges for items and services that meet the requirements for co-providers and co-facilities
- Co-providers and co-facilities must reply no later than 1 business day after receiving the request from convening providers/facilities
- Deadlines for delivery to the patient depends on the timing of the scheduled service.
- If requested or scheduled at least 10 days prior to furnishing a service, the GFE must be provided to the patient no later than 3 business days after scheduling
- If scheduled at least 3 to 9 days prior to furnishing a service, the GFE must be provided to the patient no later than 1 business day after scheduling
- No GFE is required for care scheduled less than 3 days prior to furnishing a service
"Reasonably Expected" as pertains to Uninsured and Self-Pay Patients
The "reasonably expected" standard applies both to the primary item or service and to items and services expected to be necessary in conjunction with that primary item or service, whether by a provider, convening facility, co-provider, or co-facility. Be aware that this includes circumstances "where a convening provider or convening facility anticipates that certain items or services will need to be separately scheduled (such as those items or services typical of the standard of care), the convening provider or facility must include a separate list of items or services that the convening provider or facility anticipates will require separate scheduling and that are expected to occur either prior to or following the expected period of care for the primary item or service."
Retention Requirements
A GFE becomes part of the patient's medical record and the convening provider must retain a copy of the GFE for at least 6 years.
Patient Provider Dispute Resolution Process for Uninsured or Self-Pay Patients
If the total charges billed to an uninsured patient are in "substantial excess" of the GFE the patient has the right to initiate a dispute resolution process. For calendar year 2022, the regulations define substantially in excess to mean that the total of the billed charges is more than $400 greater than the GFE. Initiation of the dispute resolution process must be made within 120 calendar days from when the patient received the initial bill for the item or service that exceeds the GFE.
Once the provider/facility receives notice, bills at issue may not be moved into collections nor may the threat of collections process be made for the items or services in dispute and accrual of all late payment fees must be suspended. However, once the dispute resolution process has started, parties can still negotiate a settlement amount.
