The No Surprises Act, effective Jan. 1, 2022, requires that healthcare providers include a “Good Faith Estimate” that covers all relevant codes and charges. This was established to increase price transparency for patients. For a summary of the No Surprises Act, read our previous blog.
In our recent webinar, hosted on December 15, 2021, industry expert Stanley Nachimson, principal of Nachimson Advisors*, answered our audience’s most pressing questions about “Good Faith Estimates.”** To read the FAQs from our first webinar, click here.
Here’s what Nachimson had to say:
Q1: What are the top things to do now to prepare for the No Surprises Act by Jan. 1?
- Set up processes to avoid out-of-network billing for emergency and in-network facility services
- Out-of-network providers need to make sure they have the right processes set up to avoid surprise billing patients.
- Evaluate in-and-out of network status for all providers
- Implement Good Faith Estimate for Uninsured/Self Pay from a single provider
- Make sure to have a process in place for self-pay or uninsured patients
- Prepare patient notice documents
- Train staff and ensure they’re aware of new rules and changes
Q2: What must be included in the Good Faith Estimate starting 1/1/22?
SN: Starting Jan 1, 2022, the only Good Faith Estimates required are for “self-pay” or uninsured patients. These are the only ones that will be enforced/mandated on January 1st.
CMS has created forms that show what GFEs should include. This includes individual services that will be provided in an encounter, line-item descriptions of services, procedure codes, diagnosis codes, and more. Estimates should be within $400 of the final bill for any provider or facility that was included, assuming there are no extenuating circumstances.
Q3: How should providers deliver the Good Faith Estimate to the patient? Payers?
SN: For patients, Good Faith Estimates should be delivered in a written document. This can be done through email, USPS, or delivered in person.
Currently, providers do not need to worry about sending anything to payers. Regulators put this requirement on indefinite hold until they have more clarity on the technical delivery/transition of this data. CMS expects to provide a ruling clarification on this in 2022.
Experian Health is now offering a FREE comprehensive, updated list of No Surprises Act (NSA) payer policy alerts for United States hospitals, medical groups, and specialty healthcare service organizations.Learn more
Q4: What are the differences between Insured & Self-Pay Good Faith Estimates that providers should consider starting Jan. 1?
SN: There will probably be no significant difference in the GFEs for self-pay vs insured individuals. However, the GFEs will be sent to health plans for the insured individuals.
At this point, there is no standard electronic delivery method. Individual providers/organizations may come up with their own paper or electronic form, assuming it contains all the required information. At some point in the future, the GFEs will be sent to health plans for insured patients, and that will most likely be a standard transaction. CMS is currently waiting on guidelines for what this transaction will look like.
Q5: How does an estimate get calculated when there are multiple providers involved? Who is the “convening provider?”
- A convening provider is the provider that (1) is responsible for scheduling the primary item or service(defined as “the initial reason for the visit”), or (2) receives a request from an individual shopping for an item or service)—must determine at the time an item or service is scheduled or when a patient is shopping for care whether the patient is a self-pay patient, as defined above.
- This will not be enforced on Jan. 1, 2022. In 2022, each provider will be expected to provide the GFE for their own services. Because there aren’t any processes in place, the healthcare industry will have at least 1 year to develop a standard guideline for gathering this information. The requirement that the convening provider combines all provider GFEs into one GFE will not be enforced until 2023.This means that over the course of 2022, the convening provider will not be required to include estimates from other providers. The industry will need to create a standard guideline and establish communication processes first. Until then, patients will need to ask every provider involved for a Good Faith Estimate. Providers may wish to consider how they will accomplish this during 2022.
Q6: Does the Good Faith Estimate apply to all services – even office visits? Labs? Urgent care? Drop-ins?
SN: It applies to all types of services. However, depending on when the service is scheduled, the timeframe will vary on when the Good Faith Estimate can be sent out.
Q7: If the actual charges are more than $400 greater than the Good Faith Estimate, what consequences will be there for providers starting Jan. 1?
SN: The latest rule established an independent dispute resolution process. The patient must initiate the process within 120 days of receiving the bill, file the required documentation and pay a $25 administrative fee.
Webinar Series: Unpacking The No Surprises Act and Q&A with an expert
Industry expert Stanley Nachimson, Health IT Implementation Expert, recently hosted a series of webinars to help providers get up to speed on what they need to do to comply with the No Surprises Act. Learn about the Good Faith Estimate, how NSA will apply in different care settings, and more.
*Stanley Nachimson is not an employee or representative of Experian Health.
**The scope and details of the No Surprises Act are evolving. The information provided here is up to date as of December 23, 2021.
This content is intended for information and education purposes only. Experian Health cannot and does not provide legal and compliance guidance. It is recommended that all organizations review the regulation thoroughly and seek appropriate legal and compliance guidance to determine an appropriate strategy for compliance. Experian Health offers solutions across the healthcare journey – including patient engagement, revenue cycle management, identity management, care management and analytics – that may contribute to meeting compliance requirements.