No Surprises Act – What You Need to Know
The No Surprises Act aims to increase price transparency and reduce the likelihood that clients receive a “surprise” medical bill by requiring that providers inform clients of an expected charge for a service before the service is provided.
Beginning January 1, 2022, all healthcare providers and facilities operating under the scope of a state-issued license or certification will be required by law to give uninsured and self-pay patients a good faith estimate of costs for services that they offer, when scheduling care or when the patient requests an estimate.
What is a good faith estimate?
A good faith estimate, or GFE, is a written document that must be presented to a patient before services are provided and must contain the following information:
- The patient’s name and date of birth;
- A description of the primary item or service being furnished to the patient (and if applicable, the date the primary item or service is scheduled);
- An itemized list of items or services that are “reasonably expected” to be furnished;
- Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;
- The name, National Provider Identifier, and Tax Identification Number (TIN) of each provider or facility represented in the good faith estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished. (APA recommends using a business TIN rather than your SSN);
- A list of items or services that the provider anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service;
- A disclaimer that there may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate;
- A disclaimer that the information provided in the good faith estimate is only an estimate and that actual items, services, or charges may differ from the good faith estimate;
- A disclaimer that informs the patient of their right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the good faith estimate. This should include instructions for where the patient can find information about how to initiate the dispute resolution process, as well as a statement that the initiation of a patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to the patient; and
- A disclaimer that the good faith estimate is not a contract and does not require the uninsured or self-pay individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate.
Click here to view further instructions and a sample good faith estimate template by The Centers for Medicare and Medicaid Services (CMS).
What is the timeline for providing a GFE?
- If the item or service is scheduled at least 10 business days in advance, the GFE must be provided within three business days.
- If the item or service is scheduled at least three business days in advance, the GFE must be provided within one business day.
- If the individual requests such information, the GFE must be provided within three business days.
- If a service is scheduled less than three business days before the appointment, no GFE is required.
- Information regarding the availability of a GFE must be prominently displayed on a provider’s website, as well as in the office or on the site where scheduling and questions about the cost of health care occur. The notice must be made available in either paper or electronic format and in the language spoken by the patient. The U.S. Department of Health and Human Services has created a model notice for providers and facilities to use called Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act. The provider or facility must fill in the blanks with the appropriate information.
- Psychotherapy is a reoccurring service; therefore, you can provide a GFE covering up to one year of services. The structure your GFE must strike a balance between advising patients about the potential high end of fees, to reduce the risk of your actual billing exceeding your GFE and giving patients a more realistic view of costs if treatment goes well and there are not complications. APA’s GFE template form provides an example of how to satisfy both needs.
- It is not enough to provide your rates per session to a new or established patient. The estimate should include the rates per session of the service(s) you anticipate providing to the patient, as well as the projected number and frequency of sessions.
- The information provided in the GFE is only an estimate, and the actual items, services, or charges may differ from what is included in the good faith estimate. However, uninsured or self-pay individuals may challenge a bill from a provider through a new patient-provider dispute resolution process if the billed charges substantially exceed the expected charges in the GFE. “Substantially exceeds” means an amount that’s at least $400 more than the expected charges listed on the GFE.
- A GFE must be included in a client’s medical record, including the date and method of delivery. It should be secured and retained in accordance with standards for other medical records. A copy of the estimate must be made available upon request for at least six years after it was initially provided.
Disclaimer: This article is for informational purposes only and is not intended to provide legal advice. For guidance specific to your practice or for further questions, you might consider consulting your professional society or your liability insurance/legal consult.