The No Surprises Act protects patients from receiving a surprise medical bill by prohibiting balance billing and requiring providers to provide good faith estimates (GFE) of services. A GFE should be provided to all patients who are uninsured and should include all services expected to be provided by both primary and co-providers.
While the legislation went into effect on January 1, 2021, HHS did recognize that providing the GFE will take some coordination between the primary and co-providers, and therefore will exercise enforcement discretion on a GFE that does not include all services until December 31, 2022.
Examining the GFE Requirements
Below is a high-level summary of the requirements for providing a good faith estimate.
- Patient name and date of birth
- Description of primary item or service in clear language
- Itemized list of convening services to be provided grouped by co-provider or facility
- Expected service codes and charges and applicable diagnosis codes if required to calculate GFE
- Name NPI, and TIN of each provider
- List of items or services, that the convening provider anticipates will require scheduling
- Disclaimer that includes: there may be additional services the convening provider recommends as part of care; the GFE is not a contract but only an estimate; the patient has a right to dispute the GFE
For a complete list of information required in the GFE review pages 35 and 42 of the No Surprises Act Good Faith Estimate and Patient-Provider Dispute Resolution Requirements from CMS.
While the primary provider with direct patient contact is responsible for providing the GFE to the patient, co-providers are impacted by not providing their expected cost. When the GFE differs from the actual charge by a certain amount patients can dispute the service.
When the GFE Differs from the Actual Charge
The legislation recognizes that it may be difficult to estimate the exact charge of service, and that is why there is a $400 limit on when a patient can dispute the Good Faith Estimate.
The GFE may include expected costs from more than one provider. Patients are only eligible for the patient-provider dispute resolution process if their bill from an individual provider or facility is at least $400 more than the total expected costs on the good faith estimate from that provider or facility.
There is a $25 non-refundable administrative fee that the patient must pay to start this process and the patient has 120 days from the date on the bill to initiate a dispute. While there is no cost to the provider for this process, the real cost is patients not having to pay their bills in full because they have embarked upon a dispute.
When the GFE is $400 more than the expected cost from that provider or facility, the patient can initiate a dispute process. CMS provided examples of good faith estimates that do and don’t qualify for the dispute process. The example below provided in the document, demonstrates how the process takes into account each individual provider’s GFE compared to their billed amount and not the total for all providers.
How Your Billing Provider Can Help
Compliance with providing a GFE will require a new level of communication between providers.
The following are ways providers can leverage their billing systems to provide a GFE:
Understand your payor mix.
Identify what percentage of your revenue comes from self-pay or uninsured patients. Determine which facilities or ordering providers have the largest self-pay population and what are the most common self-pay test. This information will help you determine which providers or facilities to start developing a process with first.
Incorporate self-pay fee schedule.
Evaluate your self-pay fee schedule to ensure it is up to date with your most commonly ordered test. Provide that list to facilities or ordering providers with direct patient contact. Ensure your self-pay fee schedule list includes test names and test codes along with descriptions for each test on the list so providers can correlate the test ordered with the self-pay rate.
Utilize patient responsibility estimator tools.
Patient estimation tools can assist patients in understanding their out-of-pocket expenses before a test is performed. Leveraging a patient out-of-pocket estimation tool can proactively educate patients before receiving a bill and help them understand their out-of-pocket costs.
Contact facilities or ordering providers.
Utilizing the information obtained from your billing system, contact facilities and ordering providers to ensure they are aware of the new requirements and implement a plan for providing the GFE for your service.
On average, 90% of all self-pay bills get paid. When implemented correctly, this new process can provide an opportunity to educate patients about the expected cost before performing a service and provide patients with a chance to determine if they wish to proceed with the service. This in turn may help reduce your unpaid self-pay bills.
Additional XIFIN Resources:
Visit the XIFIN No Surprises Act Resource Center which includes FAQs, complimentary webinars, NSA industry news, and resources from industry experts.Visit XIFIN NSA Resource Center
Additional CMS Resources:
- Understanding costs in advance
- Good Faith Estimate Example
- Good Faith Estimates FAQ 2021
- FAQs About Consolidated Appropriations Act, 2021 Implementation – Good Faith Estimates (GFE) for Uninsured (or Self-Pay) Individuals – Part 2
- No Surprises Act Good Faith Estimates and Patient-Provider Dispute Resolution
- How to know if you can dispute your medical bill