Extra, extra! Read all about it! Some new legislation is taking effect in 2022—and it affects PTs, OTs, and SLPs who provide cash-pay services to uninsured or self-pay patients. Using this resource from the Centers for Medicare and Medicaid Services and this resource from the APTA, we’ve put together an FAQ-style explainer to help you navigate everything you need to know about the No Surprises Act. Read on for more details!
What is the No Surprises Act?
The Real Life Scenario
Okay, picture this. You’re having a medical emergency—your appendix burst—and you need to rush to the hospital to get surgery as quickly as possible. Your family doesn’t think they can drive you to the hospital fast enough, so they call an ambulance. That ambulance takes you to an ER, you go into surgery, and you emerge hours later with a clean bill of health.
But that’s not the only bill you get.
Turns out that while the hospital was totally in network, none of the docs (or the ambulance for that matter) were in-network for your insurance plan, and you’re stuck with a mondo out-of-network bill that you weren’t expecting.
The goal of the No Surprises Act is to stop those scenarios in their tracks.
The Cut and Dry Legislative Info
Per the APTA, the No Surprises Act was a bill passed in 2020 that was designed to protect patients from surprise medical bills (i.e., balance billing) that occur “most often when the patient couldn’t choose their provider, such as in an emergency.” As a result, a majority of the mandates in the act apply to emergency services, emergency travel, and out-of-network providers at in-network facilities (e.g., anesthesiologists, surgeons, radiologists).
What part of the No Surprises Act applies to PTs, OTs, and SLPs?
While most of the No Surprises Act applies to providers and facilities who furnish emergency services, there is one mandate called the Good Faith Estimate that applies to everyone. Or, as CMS so deftly put it, “No specific specialties, facility types, or sites of service are exempt from this [the good faith estimate] requirement.”
Then what are Good Faith Estimates?
Good Faith Estimates (GFEs) are basically what they sound like; they are estimates provided in good faith (i.e., they are as accurate as possible) to uninsured or cash-pay patients for services they have yet to receive. This tells patients how much they can expect to pay for a service beforehand—thus eliminating surprise bills.
Are there any unusual rules about how I need to provide these Good Faith Estimates?
Good question. Yes! There are lots of very specific rules surrounding how providers need to distribute Good Faith Estimates. Here they are in a bulleted list:
- Providers must orally inform uninsured or self-pay patients that they will receive an estimate either upon scheduling an appointment, or upon request.
- The GFE must be available in the patient’s spoken language and written in clear, understandable language.
- GFEs must factor in any financial assistance for which the patient may be eligible (e.g., sliding scales, discounts, financial assistance programs).
- GFEs must be delivered either as a paper copy or an electronic file—even if the patient requests another delivery method.
- If delivered as a hard copy, GFEs may be delivered in person or mailed to an address requested by the patient.
- If delivered as an electronic file, GFEs must be both savable and printable (e.g., a PDF or a Word Document).
- GFEs are considered part of a patient’s medical record, and therefore must be kept on file for six years at minimum.
- GFEs expire after one year and must be reissued if the patient seeks services after that time.
- The actual charge of a service must total no more than $400 more than the cost listed on the GFE. (If it does, the patient can dispute the bill.)
On top of all that, GFEs must be provided in one of the following timeframes:
| If | Then |
| The appointment is scheduled three to nine days before the service | Provide the estimate no later than one business day after the appointment is scheduled |
| The appointment is scheduled 10 or more days before the service | Provide the estimate no later than three business days after the appointment is scheduled |
| The patient requests a good faith estimate without scheduling an appointment | Provide the estimate no later than three business days after the request |
And if you need to update a good faith estimate that’s already been given to a patient, “provide a new good faith estimate no later than one business day before the scheduled appointment.”
What exactly goes on a Good Faith Estimate?
Before we list out the very long list of very specific information that must be included in a GFE, we encourage you to check out this Good Faith Estimate template courtesy of CMS. It should help you tick off the requisite compliance boxes.
But without further ado, a GFE should contain the following information:
- The patient’s name and date of birth
- A description of the service or item that the provider will furnish per the patient’s reason for visiting (e.g., initial evaluation)
- The date of the scheduled service (if applicable)
- “An itemized list of items or services, grouped by each provider or facility, reasonably expected to be furnished for the primary item or service” (e.g., one unit of 97161, $75)
- The patient’s primary diagnosis code (and secondary diagnosis code, if applicable)
- The name and NPI of the provider(s) named in the GFE
- The tax identification number (TIN) of each provider or facility named in the GFE
- The location where the provider will furnish the services
- A list of items or services that you expect will require additional scheduling to furnish
- Disclaimers (and a lot of them)
- One must state that you’ll provide additional GFEs to patients upon request.
- One must state that, for any listed items that will require additional scheduling, you will provide additional GFEs upon scheduling or separate request.
- One must provide instructions as to how to obtain additional GFEs.
- One must inform the patient “that you may recommend additional services or items as part of the course of care that must be scheduled or requested separately and are not reflected in this good faith estimate.”
- One must clarify to the patient that GFEs are just that—estimates. Actual charges may differ.
- One must inform patients that they have the right to dispute bills if they are substantially higher than the GFE indicated. This must also include information as to how to begin the Patient-Provider Dispute Resolution Process.
- One must clarify that GFEs are not contracts and that patients may refuse services or treatment from the providers or facilities listed therein.
A word of advice: Use that GFE template provided by CMS.
What happens if I don’t follow all of these rules?
If you don’t follow all of the GFE rules, patients may be able to dispute their bills and avoid paying them. But more importantly, per this legal news source, “HHS may impose a corrective action plan and/or civil monetary penalties of up to $10,000 per violation.”
When does the No Surprises Act take effect—and how should I prepare for this?
The No Surprises Act—and the corresponding Good Faith Estimate requirement—took effect on January 1, 2022. So, if you’re not already providing these estimates to your uninsured and self-pay patients, it’s time to start.
Will I ever need to provide Good Faith Estimates to insured patients?
Maybe—though it’s tough to say for sure. The Department of Health and Human Services (HHS) “has not yet issued rulemaking related to the provision of GFEs for individuals who are enrolled in a plan or coverage and are seeking to have a claim submitted to their plan or coverage.” All this means is that the HHS will not act on providers who don’t provide GFEs to insured patients—for now.
Now that’s what we call big news! Credit where credit is due to these wonderful resources from CMS and the APTA—check ‘em out if you’ve got a chance!
Got any more questions about Good Faith Estimates? Drop ‘em below and we’ll do our best to find you an answer.
