No Surprise Act InformationJan 02, 2022
The No Surprise Act has been quite the buzz....well, everywhere! I know I've been collecting information and creating forms/updating my website in preparation. It seems like it almost came out of nowhere too! This blog is going to be very wordy and not very pretty, but it's informational!
Personally, as a whole, I think it's a great idea that providers need to be very transparent about being out of network with someone's insurance. I know I've been hit with medical bills when I thought I was going in-network and it turns out the doctor was out of network. Had I known this, I would have gone somewhere else.
However, I do think the very quick timeline for us to get this all set up and out is really stressful--I wish they had given us 6 months' notice. It's also a bit strange that clinicians are included in this at all as we are not the ones giving our clients very large medical bills that they cannot pay (at least I hope not!).
I strongly encourage you to reach out to your mental health attorney so they can help you create verbiage.
I reached out to the Illinois Mental Health Counseling Association to provide insight on the legislation and they sent out this email blast a few days ago with a great breakdown (it has a lot of the same stuff I've already read but alas!):
The No Surprises Act (NSA) establishes new federal protections against surprise medical bills that take effect in 2022. Surprise medical bills arise when insured consumers inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose.
What providers and what services are subject to this rule?
What steps do I need to take and when?
Under the new rule, providers must take the following steps for their uninsured or self-pay patients:
- Ask if the patient has any kind of health insurance coverage (including government insurance programs like Medicare, Medicaid, or Tricare), and if so, whether the patient intends to submit a claim to that insurance for the service.
- Inform all uninsured and self-pay patients that a good faith estimate of expected charges is:
- available in a written document that is clear, understandable, and prominently displayed;
- orally provided when the service is scheduled or when the patient asks about costs; and
- available in accessible formats, and in the language(s) spoken by the patient.
3. Provide a good faith estimate of expected charges for a scheduled or requested service, including items or services that are reasonably expected to be provided in conjunction with such scheduled or requested item or service.”
Timeframes in which you have to provide the GFE:
That estimate must be provided within specified time frames:
- If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;
- If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling; or
- If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request. A new good faith estimate must be provided, within the specified time frames if the patient reschedules the requested item or service.
What is the good faith estimate based on?
- the cash pay rate or rate established by a provider for an uninsured (or self-pay) patient, reflecting any discounts for such individuals; or
- the amount the provider would expect to charge if the provider intended to bill a health care plan directly for such item or service.
Is the good faith estimate binding?
What information should the good faith estimate contain?
The Centers for Medicare and Medicaid Services (CMS) have provided instructions and a
sample good faith estimate template (PDF, 163KB) and this one Good faith estimate
(GRAB THE DISCLAIMER LINGO!!)
A Good Faith Estimate must contain the following information in clear and understandable language:
- The patient’s name and date of birth;
- A description of the primary item or service being furnished to the patient (and if applicable, the date the primary item or service is scheduled);
- An itemized list of items or services that are “reasonably expected” to be furnished;
- Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;
- The provider's name, National Provider Identifier, and Tax Identification Number (TIN) of each provider or facility represented in the good faith estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished.
- A list of items or services that the provider or convening facility (the provider or facility that handles the scheduling of the service) anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service; 1
Disclaimers that must be included:
- A disclaimer that there may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate;
- A disclaimer that the information provided in the good faith estimate is only an estimate and that actual items, services, or charges may differ from the good faith estimate; and
- A disclaimer that informs the patient of their right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the good faith estimate. This should include instructions for where the patient can find information about how to initiate the dispute resolution process, as well as a statement that the initiation of a patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to the patient; and
- A disclaimer that the good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate.
Do these requirements apply to existing/ongoing patients?
Can I provide a single good faith estimate to a patient who I anticipate treating throughout the year?
I provide services in a setting offering multiple kinds of services to the same patient (i.e., a federally qualified health center, rural health clinic, hospital), and I do not separately schedule appointments or bill for my services. Does this rule apply to me?
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