Good Faith Estimate: Abiding by the No Surprises Act

January 28

Health care reform has been a major concern of congress over the last 25 years. A huge part of that discussion has been the huge cost to patients for medical treatment, even when they are covered by insurance. Recently, a law was enacted called the No Surprises Act that is meant to help patients understand the out of pocket cost they are going to be subject to as a result of their medical treatment. Implemented on January 1, 2022, medical providers are now required by law to notify patients about how much their financial responsibility will be for any type of treatment. The thought is that a good faith estimate will allow patients to make better informed decisions about their physical health as well as their financial health. That all sounds great, but what does that really mean for the patient and for the provider?

What is the No Surprises Act?

As the name suggests the No Surprises Act is intended to protect patients and consumers from exorbitant and “surprise” medical bills.  An increasing number of consumers receive care from an out-of-network provider or an out-of-network facility, often unknowingly, and the patient’s health plan may not have covered the entire out-of-network cost.

Several studies estimate that “surprise medical bills” happen about 1 in every 5 emergency room visits, in addition to 9-16% of in-network hospitalizations for non-emergency care.  According to a statement by the HHS, “more than half of U.S. consumers report having received an unexpectedly large bill.”

CMS.gov also states the intention to “remove consumers from payment disputes between a provider or health care facility and their health plan.”  These provisions establish an independent dispute resolution process for payment disputes between plans and providers and allows for  new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.

The Good Faith Estimate provision of the No Surprises Act is intended to give patients predictability in how much they will be charged for the healthcare services they will be receiving, prior to their appointment. 

Good Faith Estimates

As of January 1, 2022, certified health care providers are required to provide a Good Faith Estimate of healthcare charges to every new and continuing patient or client who is either uninsured or does not intend to submit an insurance claim.

Staff will be required to ask clients if they have insurance and if they intend on using their insurance on services.  If a patient answers no to either question providers will be required to disclose an estimated cost of services in advance of their appointment. 

Over time this will become a routine in every office similar to other disclosure paperwork in your practice, such as the Notice of Privacy Practices required for covered entities under HIPAA.

Does our practice need to comply with the No Surprises Act and provide a Good Faith Estimate?

The law applies to all licensed healthcare providers.  If you are a licensed or registered provider in your state, you likely need to abide by the Act. No specific specialties, types of service, or facilities are exempt.

A Good Faith Estimate is not required for a client or patient who is planning to use their insurance benefits to cover your services.  However, the HHS has hinted that future legislation may include such provisions.  

Which clients need to be given a Good Faith Estimate?

Any uninsured patient.  Additionally, any patient who is insured but does not plan to use their insurance benefits to pay for the  services you provide should be given a Good Faith Estimate. 

What information needs to be included in a Good Faith Estimate?

You can find the CMS Template here

  • Client name 
  • Client date of birth
  • Description of the services that will be provided, in understandable language
  • Itemized list of goods or services reasonably expected to be provided in connection with the scheduled services
  • Diagnostic codes, service codes, and expected charges associated with each of those goods or services
  • Provider name, NPI, and tax ID number
  • Office location where services will be provided

When do clients need to be given the 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 any 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. 

Can I include the Good Faith Estimate with my usual client intake paperwork?

Yes!  The simplest solution is to provide a Good Faith Estimate as part of your standard intake paperwork.  A Good Faith Estimate must be specific services to be provided to that client.  This can become a challenge if your practice is still using pen and paper.  

Online Patient Forms are a simple solution to completing and documenting a Good Faith Estimate has been provided.  By leveraging logic and workflows in online patient forms your practice can automatically deliver a Good Faith Estimate for a specific client and their expected services.   

Allowing patients the ability to make informed financial decisions about their medical care is important, but may cause unneeded stress and excess paperwork to medical providers. Don’t let the No Surprises Act disrupt the workflow in your office. With PatientStudio you can quickly and easily integrate a Good Faith Estimate into your existing client intake forms. Set up a demo today to see just how seamless the process can be.

You may also like

The Truth About Value Based Care

The Truth About Value Based Care

The Ultimate Practice Growth Software

PatientStudio is the one-stop practice management platform for adult and pediatric therapy clinics.  Leverage a suite of tools proven to maximize your time and grow your practice.