Uninsured, Self-Pay Patients
The No Surprises Act (NSA) provides consumer protections against unexpectedly high medical bills. When it comes to compliance, the rules differ depending on the situation. In part one of our series on The Nuances of Operational Compliance Under the No Surprises Act, we covered the law and its requirements for billing insured, out-of-network patients.
For part two, we’re breaking down how to comply with the rules for uninsured or self-pay individuals, including:
- Who’s an uninsured or self-pay individual?
- What’s a “good faith estimate” (GFE)?
- Who’s obligated to provide a GFE?
- What are the GFE timeframe and delivery method requirements?
What do you need to know when it comes to uninsured, self-pay patients?
Uninsured or self-pay individuals are eligible to receive a “Good Faith Estimate” (GFE) notifying them of what they’ll be expected to pay for treatment before receiving a scheduled or requested item or service. Note, this doesn’t apply to unanticipated or emergent care.
Who’s an uninsured or self-pay individual?
To determine if an individual is uninsured or self-pay, the provider or facility must ask if the individual is enrolled in:
- A group health plan;
- Group or individual health insurance coverage offered by a health insurance issuer;
- A federal healthcare program, or
- A health benefits plan under a Federal Employees Health Benefits (FEHB) Program
If not enrolled in any of the above, the individual is considered uninsured for the purposes of the GFE.
If they are enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, or an FEHB plan, the convening provider or facility must ask if they’re seeking to have a claim submitted with such plan or coverage for the items or services. If not, they’re considered self-pay for the purposes of the GFE.
In short, provide a GFE when one or more of the following conditions applies:
- Uninsured: patient doesn’t have health insurance under an individual, group or FEHB plan
- Self-Pay: active health insurance coverage but patient is choosing not to use it for covered services
- Non-Covered: active health insurance coverage but individual’s requested item or service is not covered
- Upon Request: individual requests a GFE for certain items or services they haven’t yet scheduled
Per guidance from the U.S. Department of Health and Human Services (HHS), enrollees in federal healthcare programs are not eligible to receive a GFE as there are other surprise billing protections under these programs.
Also, while not stated directly in the rules or guidance, an individual isn’t considered to be enrolled in a health plan for purposes of the GFE requirements if they only have coverage through workers’ compensation or auto. For these individuals, a GFE will need to be provided when items or services are scheduled or requested.
Another important point to note for front-end education: if a patient is enrolled in a health plan, the rules expect the facility to ask if they want that health coverage billed for the services. Front-end staff must also be able to identify situations where the individual may be enrolled in a health plan, but the requested items or services are not covered, and how non-coverage will trigger the requirements of the GFE.
So, what constitutes a GFE?
The Centers for Medicare & Medicaid Services (CMS) offers a downloadable GFE standard form template for compliance (Right to Receive a Good Faith Estimate of Expected Charges). HHS considers its use to be good faith compliance with the GFE requirements to inform an individual of expected charges. We recommend reviewing the model notice to understand what data elements must be included and then assess how you’ll accomplish this operationally for your facility.
- GFEs must include an itemized list with service and diagnosis codes of 1) “primary item(s) or service(s)” (i.e., the initial reason for the visit) and 2) additional items or services reasonably expected to be provided in conjunction (even if rendered by another provider or another facility, such as imaging and lab services).
- The expected charges for each listed item or service must be included with any expected discounts. “Expected charges” can be the gross charges or chargemaster rates established by a provider or facility for an uninsured (or self-pay) individual. But to ensure accuracy, HHS also wants this estimate to reflect all discounts for uninsured or self-pay individuals, including any applicable financial assistance policy.
- Lastly, the GFE must show the expected charges during a “period of care,” meaning the day or multiple days the scheduled or requested item(s) or service(s) will or are anticipated to be provided.
This spans any facility equipment and devices, telemedicine services, imaging services, laboratory services and preoperative and postoperative services the patient wouldn’t schedule separately. Keep in mind, it doesn’t matter whether the convening provider or facility, co-providers or -facilities are furnishing the item(s) or service(s).
A NOTE ABOUT DISCLAIMERS
Check out this CMS guidance that provides a full list of GFE content requirements. Among other things, it covers these four disclaimers to include:
- There may be additional items or services recommended as part of the course of care that must be scheduled or requested separately and are not reflected in the GFE.
- The information provided in the GFE is only an estimate and actual items, services or charges may differ.
- An individual has the right to initiate the dispute process if the actual billed charges are substantially more than the expected charges in the GFE. State that doing so won’t adversely affect the quality of healthcare services they receive. And include instructions for finding information on how to initiate the process.
- The GFE isn’t a contract and doesn’t require the individual to obtain the items or services from any of the providers or facilities identified in the GFE
Who’s obligated to provide it?
Involving and educating your patient access team will be necessary to first identify where an individual is uninsured or self-pay, then identify how this triggers the obligation to inform them of the availability of a GFE both in writing and orally.
Convening healthcare provider or healthcare facility: the entity that receives the initial request for an estimate and is responsible for scheduling the primary item or service
Convening providers or facilities must inform uninsured or self-pay individuals that GFEs of expected charges are available to them. This information must be provided in writing and orally during scheduling an item or service or when the patient has questions about the cost of their care.
CMS also offers a downloadable notice of the availability of the GFE (CMS Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges). While using this model notice isn’t required, HHS considers its use to be good faith compliance with the GFE requirements to inform an individual of their rights to receive such a notice. Information regarding the availability of the GFE must be:
- Clear and understandable, available in accessible formats and in the individual’s language
- Prominently displayed
- Posted on the provider or facility’s website (and easily searchable from a public search engine)
- Posted in the provider or facility’s office, and on-site where scheduling or questions about the cost of items or services occur
Co-providers or facilities: any additional providers or facilities that will furnish items or services that are customarily provided with the primary item or service
- Co-providers and facilities must submit GFE information upon the request of the convening provider or facility no later than one business day after they receive the request.
- If any changes are made to their previously submitted estimate, they must notify the convening provider or convening facility.
- If those changes occur less than one business day before the item or service is scheduled, they must accept the amounts reflected in the original GFE as expected charges.
Here, communication and coordination with different departments are necessary to identify situations where the facility will be the convening facility and situations where it may only be the co-facility and the differing obligations between those two roles.
From Jan. 1 to Dec. 31, 2022, HHS will exercise its enforcement discretion in situations where a GFE provided to an uninsured or self-pay individual doesn’t include expected charges from co- providers and -facilities involved in an individual’s care. Convening providers and facilities were otherwise required to begin complying with the law on Jan. 1, 2022.
While HHS is deferring enforcement action until Jan. 1, 2023, the work should start now to assess how best to implement the mechanics of how GFEs from co-providers and -facilities will be requested, received and incorporated into the GFE provided to the individual. Start opening communications and developing workgroups to ensure smooth compliance come 2023.
What’s the timeframe?
- When a primary item or service is scheduled at least three business days before the date it will be furnished:
Provide the GFE no later than one business day after the date of scheduling
- When a primary item or service is scheduled at least 10 business days before the date it will be furnished:
Provide the GFE no later than three business days after the date of scheduling
- When a GFE is requested by an uninsured (or self-pay) individual:
Provide it no later than three business days after the date of the request
There are no exceptions to these timeframes. Any operational barriers to meeting these timeframes must be identified and resolved.
What’s the delivery method?
The GFE must be provided in written form on paper or electronically. Coordination between various departments will be necessary to ensure the individual receives the GFE according to their requested method of delivery and within the required timeframes.
Each facility will be different in how it accomplishes these requirements depending upon its system abilities and limitations, and the various departments that could be involved from patient access to IT services to the mailroom.
If delivered electronically, there needs to be appropriate safeguards for privacy and security. And the patient must be able to save and print it. If mailing a paper copy, it must be postmarked by the timeline requirements.
The language used should be clear and understandable to the average uninsured or self-pay individual. This includes considering and recognizing:
- communication, language and literacy barriers
- any vision, hearing or language limitations
- communication needs of underserved populations
- individuals with limited English proficiency
- persons with health literacy needs
The GFE may be issued to the authorized representative to the extent not prohibited under state law.
How long should you keep GFE records?
A GFE issued to an uninsured or self-pay individual is considered part of the patient’s medical record and must be maintained in the same manner. Convening providers or facilities must provide a copy of any GFE previously issued within the last six years to an uninsured or self-pay individual upon request.
It’s worth noting this obligation may pose challenges as individuals who only request a GFE may not have a medical record number or profile in the facility’s host system.
How to apply consistency to GFEs
HHS recognizes providers and facilities have some discretion in the assumptions they make regarding which items or services to include in a GFE, and that some natural variation may occur across providers and facilities in terms of which items or services they would include in an estimate.
However, HHS is of the view that it’s critical for providers and facilities to apply the same process and considerations in developing the “good faith estimate” required under other sections of the NSA to avoid consumers receiving two different estimates describing care from the same provider or facility for the same care.
Each facility or healthcare system should work through its own specific implementation of the NSA uninsured or self-pay requirements. In doing so, ensure there’s consistency across operations in how the GFE is calculated between the requirements for uninsured or self-pay individuals and patients with out-of-network health plans who are being presented with a Notice & Consent for balance billing.
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These materials are for general informational purposes only. These materials do not and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners nor any of its employees are your lawyers. Please consult with your own legal counsel or compliance professional in regard to specific legal or compliance questions you have.