Part 3: The Nuances of Operational Compliance Under the No Surprises Act

Frequently Asked Questions About Good Faith Estimates for Uninsured or 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. We broke down how to comply with the rules for uninsured or self-pay individuals, including everything you need to know about a Good Faith Estimate (GFE) in part two. Closing out the series, we’re responding to some frequently asked questions about GFEs and sharing helpful NSA-related resources. 

Q: What if the GFE must be updated or revised?  

New (i.e., updated) GFEs are due to the uninsured or self-pay individual when information used to create the original GFE changes.  

The new estimate must be issued no later than one business day before the item or service is scheduled. The same applies if there are any changes in the expected providers or facilities who will be providing the items or services.  

TIP: System triggers may be established to identify instances where a new or revised GFE must be issued to an individual and to do so within the timeframes specified. Here, coordination will be needed with the facility’s IT or host system vendors. 

Q: What if errors are discovered on the GFE?  

In circumstances in which a provider or facility, acting in good faith, makes an error or omission in a GFE, a provider or facility must correct it as soon as practicable.  

If the services are furnished before the error is addressed, the provider or facility may be subject to the patient-provider dispute resolution process if the final billed charges are substantially more than the GFE. 

TIP: System triggers may also be established here in addition to establishing standard operating procedures and front-end staff training for the prompt correction of any erroneous GFEs. 

Q: What if an individual only requests a GFE but doesn’t schedule services?  

If an individual only requests a GFE but doesn’t schedule the service until after receiving the estimate, a new estimate must be provided to them upon scheduling.  

In these situations, HHS encourages reviewing any previously issued GFEs before issuing a new one, and then communicating to the individual any changes between the two upon delivery of the new estimate.  

TIP: The obligation to provide a new GFE upon scheduling an item or service may be automated through your operational systems and should be included in training and education of front-end staff. 

Q: What are the requirements for GFEs of separately scheduled items or services?  

The GFE must include a list of those items or services that require separate scheduling. It must also include a disclaimer directly above this list that notifies the uninsured or self-pay individual that:  

1. Separate GFEs will be issued to an uninsured or self-pay individual upon scheduling of the listed items or services or upon request 

2. For items or services included in the list, information such as diagnosis codes, service codes, expected charges and provider or facility identifiers may not be included as that information will be provided in separate GFEs upon scheduling of such items or services or upon request 

3. Instructions are included for how to obtain GFEs for such items or services 

TIP: Identification of those services or procedures where items or services will need to be separately scheduled will be helpful in complying with this requirement. 

Q: What are the requirements for GFEs for recurring items or services?  

GFEs may be issued for recurring primary items or services if the following are met:  

  1. It clearly states the expected scope of the recurring items or services (such as: timeframes, frequency and total number of recurring items or services) 

  1. The timeframe does not exceed 12 months. Anything beyond 12 months requires a new GFE with an explanation of any changes made since the first estimate. 

TIP: The GFE must include the additional language about the scope of the recurring services when this applies. 

Q: What are the penalties?  

Up to $10,000 penalty for each violation (balance billing, noncompliance with other requirements, etc.).  

TIP: Ensure compliance to avoid monetary penalties and the poor press that would inevitably follow. 

Q: How are disputes handled?  

A patient’s bill will be eligible for the Patient-Provider Dispute Resolution (PPDR) process if the following conditions are met:  

  1. The patient received a GFE   

  1. The process is initiated within 120 calendar days of the patient receiving the bill 

  1. The bill is “substantially in excess of the GFE” defined as at least $400 more than the total amount of expected charges listed on the GFE for any provider or facility.  

Note, as each GFE could potentially contain expected charges from multiple providers and facilities, the substantially in excess determination is made separately for each specific provider or facility listed on the GFE. 

For a summary of the PPDR process, review pages 21 to 23 of this CMS Guidance on Good Faith Estimates and the Patient-Provider Dispute Resolution Process. 

Important operational considerations for the PPDR process include the following: 

  • The PPDR process may only be initiated by the patient.  
  • The Selected Dispute Resolution (SDR) entity will notify the provider of facility through the federal IDR portal, or electronic or paper mail, or phone, that a PPDR initiation request has been received and is under review. The provider or facility will then have 10 business days to submit any required information to the SDR entity. HHS strongly recommends this be done through the federal IDR portal. 
  • Payment of all or part of the billed charges by the uninsured or self-pay individual is not an agreement to settle at that amount or any other amount and the individual may still pursue the PPDR process.  
  • All collection efforts must cease when a PPDR is pending, including the accrual of any late fees. Retributive action against an uninsured or self-pay individual is prohibited. 

Understand you may be notified in a variety of different ways of the PPDR process by the SDR entity. It’s important that, however notified of the PPDR process, your facility can route that notification to the appropriate department for production of the information requested by the SDR entity, preferably through the federal IDR portal. Training and education from the mailroom to scheduling and billing will be necessary to do so. 

Learn more about the six stages of the federal IDR process: REFERENCE: Understanding the No Surprises Act Independent Dispute Resolution Process 

HELPFUL RESOURCES 

Want help navigating the operational compliance requirements of the No Surprises Act? Contact one of our experts today. 

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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 regarding specific legal or compliance questions you have.