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April 2022 New Guidance for the Good Faith Estimate

 

This article explains the Good Faith Estimate and breaks down new guidance from the Department of Health and Human Services. To learn more, see our blog post explaining the Good Faith Estimate.

The good faith estimate and the No Surprises Act

The Good Faith Estimate (GFE) is part of the No Surprises Act (NSA), which is federal legislation designed to protect patients from surprise medical bills that went into effect January 1, 2022.  The Department of Health and Human Services (HHS) with other federal departments created the GFE to protect self-pay and uninsured  patients from receiving bills that are substantially more than expected. This article explains the Good Faith Estimate and breaks down new guidance from the Department of Health and Human Services. To learn more, see our blog post explaining the Good Faith Estimate.

The GFE is an estimate of the cost to obtain healthcare without using any type of health plan. The legislation requires virtually all healthcare facilities and providers to 1) notify self-pay patients of their right to obtain a GFE of anticipated charges; and 2) provide a GFE of charges to the self-pay patient before items or services are rendered. 

If the actual charges billed are $400 or more than the GFE, the self-pay patient may initiate what’s called the selected dispute resolution (SDR) process to determine what the patient must pay. For GFEs, the SDR process is also known as the patient-provider dispute resolution (PPDR) process.

New guidance from HHS 

The following list is what HHS clarified regarding GFEs for self-pay/uninsured patients as published by Holland & Hart:

  • Providers and facilities are not required to provide a good faith estimate (GFE) to self-pay patients who schedule services less than three (3) business days in advance, including same-day or walk-in services.

  • Providers and facilities are not required to include a diagnosis code in the GFE if the provider or facility has not yet determined the diagnosis, such as for initial screening or evaluation.

  • Providers and facilities are not required to include expected charges for future visits in the same GFE provided for the initial visit.

  • Subsequent visits will require their own GFE or the provider or facility may provide a single GFE for recurring visits if certain conditions are met.

  • The rules do not require a GFE to include charges for items or service that could not have been reasonably expected at the time the GFE was provided; however, the provider or facility may have the burden of proving the item or service was not foreseeable if the patient takes the matter through the Patient-Provider Dispute Resolution (PPDR) process.

  • A provider or facility is not required to issue a GFE if the patient’s status as self-pay changed from the time the services were scheduled and the time the patient is seen. For example, if a patient indicated they were insured at the time of scheduling, no GFE estimate is required for that visit even though it is subsequently determined that the patient is, in fact, self-pay.

  • Finally, HHS reaffirmed that providers and facilities must still comply with HIPAA when issuing the GFE.

Note: This is not a comprehensive look at all the nuances of the No Surprises Act or the good faith estimate. For more information, see our Good Faith Estimate ebook here.


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