No Surprises Act: Good Faith Estimate Requirement

As outlined in our previous Legal Briefing (see link: No Surprises Act Compliance (lawpf.com)) the federal No Surprises Act (the “Act”), enacted in 2020, created a number of requirements for health care providers. One of the provisions of the Act that went into effect on January 1, 2022 requires health care providers and facilities to provide Good Faith Estimates to uninsured or self-pay [1] individuals (“patient”) prior to scheduled services.


Under the new law, providers are required to inquire whether an individual is covered by a health care plan, and if so, whether they intend to use their health care plan benefits. If a patient is uninsured or chooses to self-pay, the provider must inform the patient of the Good Faith Estimate (“GFE”). The law defines two groups of providers, Convening Health Care Providers and Co-Health Care Providers [2] – a provider that furnishes items or services in conjunction with another provides. Currently, the law requires that each convening health care provider or facility provide notice of the availability of a GFE on the provider’s website, at the office, and on-site where scheduling and cost questions may arise, and such notice must be “clear, understandable, prominently displayed, and easily searchable.”


Under the Act, providers are obligated to provide a GFE to (1) a patient who may request one prior to scheduling care, (2) any patient who inquires about costs or discusses such with the provider, and (3) any patient once a service is scheduled.


If a patient requests a GFE prior to scheduling services, the provider is required to provide a GFE within 3 business days of the patient’s request. If the patient schedules a service at least three days before the service, the provider must provide a GFE within 1 business day. If the patient schedules a service 10 or more days out, the provider must provide a GFE to the patient within 3 business days. Additionally, if a GFE is requested prior to the patient scheduling a service, a new GFE must be provided following the above guidelines once a service is scheduled. Lastly, if a provider learns of or anticipates a change in the scope of services that will be provided, the provider is required to provide an updated GFE to the patent no less than 1 day prior to the scheduled service.

One provision that may assist providers with controlling the demand for GFE and the timelines described above is that a provider who provides a recurring service for a patient may provide a single GFE and shall update it at least every 12 months. Further, providers and facilities can provide these estimates to patients either in writing or electronically [3], whichever is requested by the patient.


To assist providers and facilities in creating a GFE for patients, the Act requires the estimate to include the following:

  • Patient’s name

  • Patient’s date of birth

  • Description of primary item or service in “clear and understandable language”

  • Date of scheduled service, if applicable

  • Items or services expected to be provided in conjunction with the primary item or service, grouped by provider and facility, and must include their diagnosis code, procedure code, and expected charge

  • Name and identifying information for each provider and facility

  • Items or services that may require separate scheduling and a separate GFE

  • Required disclaimers


Once a patient has received a GFE and subsequently a provider has provided an item or service, and the patient receives the bill, the Act has created guidance with respect to disputes. If a bill exceeds the GFE by more than $400, the patient can dispute the bill. A provider or facility will be notified of a patient’s dispute by a dispute resolution entity after such entity receives a referral from the state and determines that the dispute is eligible for dispute resolution.


Once a provider or facility receives notice, within 10 days, they must provide a copy of the disputed GFE and bill, along with any documentation showing that the difference was based on a medically necessary item or service that could not have been anticipated when the GFE was created. At that time, providers and facilities must also suspend collections and accruals of late fees on unpaid amounts for the duration of the dispute resolution process. If during the course of the dispute resolution, the patient and provider settle the dispute, the provider must notify the respective dispute resolution entity within 3 business days of the settlement.


The Centers for Medicare & Medicaid Services has created a model Good Faith Estimate form with appropriate disclaimers and can be found at the link below:

Good Faith Estimate Example (cms.gov)


Our Firm has extensive experience counseling employers and businesses on compliance requirements, as well as preparing and implementing applicable policies. If you have any questions related to this Legal Briefing, please contact any member of our Firm at 585-730-4773. Please note that any embedded links to other documents may expire in the future.


 
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This Legal Briefing is intended for general informational and educational purposes only and should not be considered legal advice or counsel. The substance of this Legal Briefing is not intended to cover all legal issues or developments regarding the matter. Please consult with an attorney to ascertain how these new developments may relate to you or your business. © 2022 Law Offices of Pullano & Farrow PLLC

[1] Self-pay individuals are insured individuals that choose to pay out-of-pocket for a particular service and not utilize their benefits. [2] For the 2022 year, the requirement that convening providers incorporate estimates from co-providers will not be enforced. Patients will be able to request a GFE directly from those co-providers. [3] If a client wishes to receive a GFE electronically, it must be in a manner that allows the patient to both save the document as well as print the document.