No Surprises Act & Good Faith Estimate

Per the No Surprises Act (effective as of 1/1/2022), a "Good Faith Estimate" must be provided to "Clients who do not have insurance or who are insured but indicate they don’t want to submit their medical bill to their insurance company. The CMS guidelines indicate that insured patients can ask for a Good Faith Estimate which will be shared with their insurance plan." For those clients who are not insured or don't want to go through their insurance, here are some basic steps you need to take to comply with the No Surprises Act good faith estimate (GFE).

Step 1: Review the guidelines

Review the guidelines and how they apply as outlined by the Centers for Medicare & Medicaid Services (CMS):

Step 2: Provide clients with a “GFE Notice”

Provide clients with a notice about their right to a GFE. You can use the Department of Health and Human (HHS) notice available here: LINK. Post this notice on your website and provide a copy when you see clients in person. You should also notify uninsured/self-pay clients (as identified in Step 4) orally about their right to a GFE when scheduling a session or when a client asks about costs.

Step 3: Create GFE templates for your practice

Ideally, you would have a template for the assessment and for treatment. If you would like assistance with creating these forms, check out our Resource Library which hosts a compilation of templates, forms, tools, and resources. Learn more here: LINK

Step 4: Determine if your client should receive a GFE

Ask each client:

If they have any kind of health insurance coverage, and
If they have private or other insurance (other than federal health insurance programs like Medicare, Medicaid, Tricare, or CHIP), they intend to use for your services

If they answer yes to both questions, you do not need to give the client a GFE at this time.

If the client is in a federal health insurance program like Medicare or Medicaid, they don’t get a GFE because those programs have their own surprise billing protections for clients. Coverage through Tricare and CHIP are not explicitly mentioned, but APA expects they will be included in this exemption.

Federal Employee Health Benefits program members do get a GFE if they don’t intend to use that insurance.

For question B, if the answer is no, regardless of whether you are in or out of network, then you do provide a GFE.

The next steps apply only to those patients who answered “no” to one of the questions in Step 4, placing them in the uninsured/self-insured category.

Step 5: Give your clients an initial GFE

When scheduling appointments:

For appointments scheduled three or more business days before the appointment date, provide the GFE within one business day after scheduling.
For appointments scheduled 10 or more business days before the appointment date, provide the GFE within three business days after scheduling.

For example, if on November 1st you schedule a session for November 7th, give the GFE by November 2nd. If on November 1st, you schedule a session for December 1st, give the GFE by November 4th.

The regulations do not address when to send the GFE if the appointment is scheduled less than three days out. If you are in that situation, we recommend that you send the client a GFE as soon as possible.

Currently, if the client reschedules the appointment, you must provide an additional GFE, within the timeframes above. (Note, this clause may be removed. Refer to the most updated notice on the CMS website).
When the client requests a GFE (without scheduling the service) you should provide the GFE within three business days of the request.

Step 6: Update your GFEs

You should provide updated GFEs to clients at least one business day before a scheduled service under the following circumstances, listed in order of priority.

There are changes to service that significantly affect the cost of care. It is most critical to make sure that your actual billing does not exceed the current GFE by more than $400, however, any changes in billing should trigger an updated GFE.
You continue to treat a client beyond the time frame of the initial GFE.
You anticipate any changes to the “scope” of the GFE, such as anticipated changes to the “expected charges, items, services, frequency, recurrences, duration, providers, or facilities.”

References

Written November 10, 2023 - By Charity Steele, MS, BCBA