The No Surprises Act and What You Need to Do in Your Practice to Be in Compliance.
The act was designed to protect consumers from receiving unexpected medical bills. As of January 1, 2022, state-licensed or certified health care providers need to give a Good Faith Estimate of healthcare charges to every new and continuing client who is either uninsured or is not planning to submit a claim to their insurance for the healthcare services they seek. You also need to inform every uninsured or self-pay client of their right to receive a Good Faith Estimate.
A Good Faith Estimate is not necessary at this time for a client or patient who is planning to use their insurance benefits to cover your services. The Good Faith Estimate provisions do not apply if the client is a participant in Medicare, Medicaid, or other federal healthcare programs.
- You may recommend additional items or services as part of the treatment that are not reflected in the estimate as your treatment progresses.
- You may not know how much therapy will be needed when a new client schedules services for the first time. In these instances, it may make sense to offer a range of potential costs that includes a potential range of sessions that may be needed. As an example, you can include on the form: Depending on how you/ your child responds to occupational therapy, you may need between 15 and 30 45 minute therapy sessions during the calendar year 2022. At $160 per session, the estimated total costs are between 15 x $160 ($2400) to 30 x$160 per session ($4800)
- Remember that the information provided in the Good Faith Estimate is only an estimate, as actual services, or charges may differ.
- The client has the right to engage in a dispute resolution process if the actual costs of services significantly exceed those listed in the Good Faith Estimate.
- The Good Faith Estimate does not obligate or require the client to obtain any of the listed services from you..
In addition to the estimate itself, clients who are not using their insurance benefits to pay for services must also be given notice of their right to receive a Good Faith Estimate upon request. The Department of Health and Human Services has a sample notice you can customize and include in your practice.
When do clients need to be given the Good Faith Estimate?
The law puts forth specific guidelines for when a client must be given a Good Faith Estimate.
- If a service is scheduled at least 10 business days in advance, the Good Faith Estimate must be provided within 3 business days. (This is within 3 business days of the scheduling, not of the appointment itself.)
- If a service is scheduled at least 3 business days in advance, the Good Faith Estimate must be provided within 1 business day of scheduling.
- If a service is scheduled less than 3 business days in advance, a Good Faith Estimate is not required.
- If an individual requests a Good Faith Estimate, it must be provided within 3 business days.
The Good Faith Estimate must be provided in writing, and if delivered electronically, must be provided in a format that the client can save and print if they wish. The estimate should also be provided verbally if the client inquires about costs, but verbal delivery must be followed up with a written Good Faith Estimate. Providing the information only in verbal form would not be considered compliant.
Can clients waive their right to a Good Faith Estimate?
While some clients will either be unaware of their right to a Good Faith Estimate or feel comfortable not receiving such an estimate, there are no provisions in the federal regulation allowing clients waiving their right to a Good Faith Estimate. The regulation allows clients to waive some of the protections related to balance billing, but does not allow providers to bypass the Good Faith Estimate through a client waiver.
How specific does a client request for a Good Faith Estimate need to be?
The regulation stipulates that any discussion or inquiry about the costs of treatment should be considered a request for a Good Faith Estimate. Clients do not need to use the exact phrase.
What if my estimate turns out to be wrong?
As noted in the rulemaking itself, the Good Faith Estimate rules “do not require the good faith estimate to include charges for unanticipated items or services that are not reasonably expected and that could occur due to unforeseen events.” If a clients’ needs are ultimately different from what was expected, a provider can update the Good Faith Estimate to address the new information or events.
How should I document delivery of the Good Faith Estimate?
The estimate itself must be included in the 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.
for consumers to find a provider who is actually in-network. Under the No Surprises Act, as of 2022 insurers must update their directories every 90 days. Providers must inform any insurances that they are in-network with, of any meaningful changes to their directory listing, and any time the provider terminates an agreement. HHS can also set forth other notification requirements.
Along similar lines, insurers are required to notify patients when the in-network status of a treating provider changes. The patient will have the option to continue with that treating provider for up to 90 days under the same payment terms that existed under the provider’s in-network contract, with some exceptions.
What’s the risk if I don’t follow this new requirement?
HHS has said it is deferring enforcement and doing some additional rulemaking for in-network services, but that it is not deferring enforcement of the requirement to provide Good Faith Estimates for uninsured or cash-pay clients. As with HIPAA, providers found to be violating the regulations can be fined.
Disclaimer: This guide is for informational purposes only, is based on plain-language reading of the regulation and related documentation, and is not intended to provide legal advice. This article and the related federal requirements may change. For guidance specific to your practice, consult an attorney.
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Notice of Right to Receive a Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
(1) You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
(2) You will be given a Good Faith Estimate in writing at least 1 business day before your medical service
(3). You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.
(4) If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill (5) Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises