If you’re a health care provider, you’ve probably heard about the recently implemented rules concerning the “Good Faith Estimates” for uninsured and self-pay patients . The good faith estimates is part of the No Surprises Act, whose implementation began on 1st January 2022. However, as is common with most Acts targeting the health industry, many questions remain on what the new rules mean to healthcare providers and self-pay patients.
Well, this post will get you up to speed with the new requirements of the No Surprises Act being implemented by the Department of Health and Human Services.
The Good Faith Estimates Regulation
Passed by Congress late last year, the newly enacted Good Faith Estimate regulation requires health care facilities to provide uninsured and self-pay patients with charges to be expected for specific health services. Besides, this information should be provided by the healthcare provider or facility once a patient schedules a service.
Under this regulation – which began on 1st January 2022 – uninsured patients refer to all patients who do not have any medical coverage plan. The provisions of this No Surprise Act require out-of-network facilities/providers and health insurers to agree on a fair price for medical care rather than leaving patients to face unexpected out-of-pocket medical expenses.
What’s more, in complying with the new regulations, health care providers will have to coordinate the estimates among each other so that patients seeking the same care from different healthcare providers don’t get highly differing estimates for Good Faith Estimates.
The Act’s provisions governing the bill further recommend that health care facilities and providers agree on standard charges for medical care. This is intended to cushion uninsured and self-pay patients against unexpected medical expenses.
Contents of a Good Faith Estimate
Following the regulations, health care facilities must include the following contents in the good faith estimates:
- The name and date of birth of the patient.
- A detailed description of the medical service – provided using a language easily understood by the patient.
- If the medical service has already been scheduled, the good faith estimate must indicate when the service is to be provided.
- A list of all the other healthcare providers who may be consulted or referred to for the same medical care.
- The applicable diagnosis or service codes and the charges associated with each service.
- The name, TIN, NPI of each healthcare provider or facility that will furnish the medical service. The state in which the facility is located must also be provided.
- If other medical services besides the primary one are to be provided before or after the primary service, the healthcare facility must prepare separate scheduling for the other services.
- A disclaimer statement.
Who Does the Regulation Apply To?
Does this new bill apply to all and sundry in the healthcare industry? The bill covers emergency and non-emergency services providers both at in-network facilities and out-of-network air ambulances. Here are a few provisions you should note;
- The No Surprise bills apply to emergency medical services provided by out-of-network healthcare facilities.
- It also includes emergency services provided at an in-network facility by an out-of-network healthcare provider.
- If you’re an out-of-network healthcare provider, you will have to comply with this new regulation for non-emergency services provided at specific in-network facilities such as ambulatory surgical centers, critical access hospitals, hospital outpatient departments and general hospitals.
However, for the purpose of “Good Faith Estimate”, the regulations utilize a broader definition of healthcare providers, thus impacting nearly all the facilities and providers in the healthcare sector. Accordingly, any state-licensed institution must provide a Good Faith Estimate to self-pay and uninsured patients under this regulation. This includes medical laboratories, federal health centers, rural health centers, imaging centers, and air ambulance medical services.
Responsibilities of Healthcare Providers
As a healthcare provider, your duties and responsibilities under this new regulation involve determining if the patient requesting the estimates is self-pay or uninsured. You can do this by inquiring if the patient is enrolled in individual health coverage provided by a health insurer, a federal healthcare program or employer health care benefits.
You can also determine if an individual is uninsured or self-pay by inquiring whether the person is enrolled in a group health plan and is seeking for submission of a claim for a medical care service with the plan.
What’s more, you could simply inform an individual of the availability of good faith estimates as soon as they schedule medical care.
Additionally, in the dispensation of the Good Faith Estimates, as a healthcare provider, you are required to:
- Provide the information in Good Faith Estimates in an understandable manner. This information must be on an easily accessible platform such as a public search engine or website.
- Provide the good faith estimates information in person during the scheduling for a service.
- A healthcare facility should consider any inquiry regarding the potential costs of an item or service as a request for the Good Faith Estimates.
- Provide the good faith estimate within a period of 24-hours and ask your co-providers and co-facility to submit the same to other healthcare providers who are covered by this regulation.
The new regulation also stipulates that healthcare providers must update their estimates a day before the service is to be dispensed if there are any changes to the scope of the service since the initial estimate was provided.
Moreover, the information provided in Good Faith Estimates must include timeframes and frequency for recurring services. An estimate for such services will only be valid for a period of 12-months.
As of 1st January 2022, any uninsured person will have the right to know the costs associated with a medical service they wish to acquire beforehand. Therefore, as a healthcare provider, you must comply with this new regulation and train your frontline workers to determine self-pay and uninsured individuals.
That said, you should note that this regulation was issued as part of an interim rulemaking process , and hence there are possibilities that it could be modified by the time the final ruling is issued. In the meantime, healthcare providers should follow this guide to ensure they are compliant with the Good Faith Estimates regulation.