The No Surprises Act & Good Faith Estimate
The No Surprise Act (NSA) is one of the biggest consumer protections against surprise medical bills which went into effect on January 1, 2022. The No Surprise Act provides consumers with federal protection from unexpected out-of-network medical bills—bills from healthcare providers who don’t participate in the patient’s health insurance network.
The implementation of the No Surprise Act in 2022 will simultaneously help move the US towards a more transparent and patient-focused healthcare system, while alleviating some of Americans’ medical-related financial burdens. In most situations where insurance does not cover for care, the NSA requires healthcare providers & facilities to issue patients a good faith estimate (GFE) form, which provides a detailed estimate of costs prior to services being rendered.
As a healthcare provider, it’s important to understand how the CMS No Surprises Act impacts your business, and how to meet compliance requirements.
What is the No Surprises Act?
The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.
Surprise medical bills are a major source of stress for many American adults and around 57% say that they’ve been sent one at some point.
The No Surprise Billing Act attempts to reduce the likelihood that patients may receive a surprise medical bill by requiring healthcare providers to give patients a good faith estimate of costs for services they offer prior to scheduling service or when the patient asks for an estimate.
Although most Americans are covered by some form of health insurance, these bills often arise in situations when they receive care from out-of-network hospitals, or healthcare providers they did not choose.
While a majority of these situations arise from emergencies, these regulations also apply to non-emergent situations as well as providers and facilities. Even if a patient is at an in-network hospital, they could unknowingly receive care from an out-of-network provider, such as an anesthesiologist.
For non-emergent care, the NSA limits out-of-network providers from balance billing for services provided at an in-network facility unless the patient has been provided prior notice and has agreed to waive such protections.
Balance billing is when providers charge patients for the difference between what insurance covers, and the out-of-network provider’s rate. Many states already have established laws against balance billing, but the new No Surprise Act regulations will seek to prevent balance billing in those remaining States with weak or no protections.
What is a Good Faith Estimate?
The Good Faith Estimate (GFE) provision of the No Surprises Act (NSA) is designed
to give consumers predictability in how much they will be charged for the services they will be receiving prior to their appointment. The GFE is meant to be used by the consumer as a comparison tool to guide decisions about choosing a healthcare provider, therefore, regardless of whether an appointment is scheduled, a Good Faith Estimate must be provided when requested.
Who is required to provide a Good Faith Estimate (GFE)?
To protect consumers from surprise billing, the NSA requires out-of-network healthcare providers to issue uninsured or self-pay patients a GFE for the cost of care, and a plain-language notice of their billing protections in advance of scheduled services.
According to the CMS No Surprises Act, no specific specialties, facility types, or sites of service are exempt from this requirement.
Healthcare provider includes all doctors and other healthcare providers acting within the scope of practice of that provider’s license or certification under applicable State law. Therefore, this provision applies to all providers, including registered dietitian nutritionists (RDNs), therapists, doctors, hospital outpatient departments, critical access hospitals, ambulatory surgical centers, rural health centers, and federally qualified health centers.
Find answers to frequently asked GFE questions on the CMS website.
GFE Form Requirements
Below is the information that must be included on the GFE, as outlined by the CMS. You can download a sample GFE from the CMS website, which includes any necessary disclaimers and No Surprise Act regulations.
- Provider Name, NPI, and TIN of all service providers and the state where the services will be rendered
- Client name and date of birth
- Clear description of service and date scheduled (if applicable)
- List of all items and services (including those to e provided by co-providers)
- CPT code, diagnosis code, and charge per item of service
- List of items from other providers that will require separate scheduling
- Disclaimer that separate Good Faith Estimate will be issued upon request for services listed in number 6, and that items in number 4 will be provided in those separate GFEs
- Disclaimer that there may be other services required that must be scheduled separately during the course of treatment and are not included in the GFE
- Disclaimer that this is only an estimate and actual services, and charges may differ
- Disclaimer informing the client of their rights to a client-provider dispute resolution process if actual billed charges are substantially above the estimate, as well as where to find information on how to start the dispute process
- Disclaimer that GFE is not a contract, and the client is not required to obtain services from the provider
Next Steps For CMS No Surprises Act Compliance
If you work in an institution such as a hospital or clinic, your next step is going to be to consult with your employer.
For providers working outside of a hospital or clinic, we recommend checking with your professional organization (ie. Academy of Nutrition & Dietetics, American Physical Therapy Association, etc) to better understand how the NSA impacts your profession, and business setting. Most professional organizations have issued statements and helpful resources to be leveraged by their professional members.
In cases where the No Surprise Act may apply, these are the steps that should be taken for compliance with the new law:
- Verify patient health insurance coverage prior to the scheduled service.
- Confirm with the patient if they plan to use their health insurance or pay out-of-pocket for the service. For uninsured, self-pay or out-of-network individuals, inform them of the availability of a GFE on scheduling the service or at the patient’s request.
- Provide an itemized good faith estimate before the service is rendered. Explain the estimate to the patient over the phone or in-person if they request it, but you’ll need to follow up with a written (paper or electronic) estimate.
- Post a standard notice & consent under the NSA, accessible to patients.
Leveraging Healthie’s EHR for NSA Compliance
Healthie is designed to give healthcare providers the tools they need to manage their practice, and connect with patients, to deliver engaging care.
A Good Faith Estimate template form has been added to Healthie’s forms library, for providers to conveniently complete and share with patients. Completed forms are securely stored in your patient’s profile, ensuring NSA compliance.
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