Private Pay

HHS releases "No Surprises Act" Good Faith Estimate Resources

Julie Lenhardt 05/20/2024

In the two years since implementation of the No Surprises Act (NSA), the Department of Health and Human Services (HHS) has continued to refine the sub-regulatory guidance to provide clarification to patients and providers. It is crucial for occupational therapy practitioners (OTPs) to stay informed about updates from HHS about the No Surprises Act and the Good Faith Estimate (GFE). Since January 2022, HHS has issued additional guidance and resources regarding the NSA and GFE, summarized below.

It should be noted that the No Surprises Act does not apply to beneficiaries or enrollees in Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE, as these programs already have protection against high out-of-pocket costs for enrollees.

As outlined in AOTA’s previous article, the Department of Health and Human Services (HHS) requires certain information to be included in the Good Faith Estimate (GFE). CMS has provided a model GFE that providers can use as a guide when issuing a GFE for their own uninsured and self-pay patients.

Example: https://www.cms.gov/files/document/good-faith-estimate-example.pdf

When a client schedules an appointment, a GFE should be provided to the client no more than one business day after the day the appointment was scheduled if the appointment was scheduled at least three business days before the actual appointment and within three business days of scheduling if the appointment is made at least 10 business days in advance.

For example, if the client calls on Monday to schedule an appointment on Friday, then a GFE must be provided to the client by the end of business Tuesday. If the patient calls on Monday and schedules an appointment for two weeks out, then the GFE must be provided to the client by the end of business on Thursday.

If a GFE is requested by the client before an appointment is scheduled, the GFE is due within three business days. Once an appointment is scheduled, a new GFE must be provided to the client.

In the case of recurring or repeat services, the OTP may provide a single GFE for recurring services as long as it is updated at least every 12 months. The GFE must be preserved as part of the patient’s medical record for at least six years, and a copy must be provided upon request.

An HHS fact sheet explaining the Good Faith Estimate for patients can be found here.
The Patient-Provider Dispute Resolution (PPDR) process applies only if, after receiving the items or services, the uninsured (or self-pay) individual is billed for at least $400 above the good faith estimate. At that point, the individual may be eligible to dispute the bill through the patient-provider dispute resolution (PPDR) process by submitting a request to HHS and paying a small administrative fee (set at $25 in 2022).

An overview document about the GFE and PPDR from HHS is available here: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/IDR_GFEPPDRAssisters_webinar_030222_5CR_030322.pdf

The CMS Center for Consumer Information and Oversight (CCIIO) offers more detailed training on the GFE and PPDR, including examples and knowledge checks, at https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/GFE-Patient-Provider-Dispute-Training.pdf.
An area of recent development applies to individuals with certain types of commercial insurance. The NSA requires providers to send an “insured GFE” to the individual’s health plan or issuer (payer). The GFE must include expected costs for each item or service, including those expected to be furnished by other providers.

The payer must then use the GFE to create an advanced explanation of benefits (AEOB) that includes the provider’s or facility’s expected charges, the portion the payer expects to cover, and the patient’s expected cost-sharing liability. This information will help patients understand their expected costs before items or services are furnished and allow them to make cost-conscious decisions about their care. Patients can also use estimates to compare prices among providers. The AEOB represents an important advancement in patient price transparency and is a critical part of the NSA’s patient protections.

However, due to input from stakeholders, enforcement of this provision has been delayed until an industry-wide data standard for data transmission between providers and payers can be developed.

Occupational therapy practitioners must be diligent and committed to navigating the evolving landscape of healthcare regulations, including the No Surprises Act. By leveraging resources from HHS and CMS and staying informed about the latest updates, practitioners can uphold compliance standards while delivering high-quality patient care.

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Additional CMS resources