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Creating such estimates for patients unfamiliar with a provider are sure to present unique challenges.

Provisions of the No Surprises Act and Centers for Medicare & Medicaid Services (CMS) regulations, effective Jan. 1, 2022, require, among other things, that all licensed healthcare providers must give “good-faith estimates” (GFEs) to uninsured/self-pay patients upon scheduling any service at least three days in advance, or upon request. The “upon request” requirements were put in place to allow patients to shop among different providers and compare prices for the same services.  

This is part of the overall purpose of the Act, which was passed to help protect patients against unforeseen medical bills and to provide greater price transparency. The GFE requirements are in place now for uninsured/self-pay patients, with requirements for commercially insured patients on hold until further industry development of standards and additional CMS rulemaking.   

CMS detailed specific requirements for the information in the GFE. These include the following:

• Patient and provider(s) identification;

• Description of the primary service;

  • Applicable diagnosis codes, expected service codes, and expected charges;
  • An itemized list of items and services reasonably expected to be furnished as part of the
  • primary service or in conjunction with that service, including their expected charges; this includes procedures, medical tests, supplies, prescription drugs, durable medical equipment (DME), and any facility fees;
  • A list of items and services that the convening provider or convening facility anticipates will require separate scheduling; and
  • Disclaimers for the benefit of the patient, which must:
    • Inform the patient that there may be additional items or services recommended as part of the course of care that must be scheduled separately;
    • State that the GFE is only an estimate;
    • State that the GFE is not a contract between the provider and patient; and
    • Make clear that the patient has the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the those included in the GFE.

The GFE is required for any set of services from licensed providers.  

When providers are scheduling services for their patients, one can expect that most, if not all, of this information is known or easily generated by the provider. Procedures, surgeries, etc. are clearly known, with the reason for the procedure (the diagnosis) generally known. An office visit or consultation has generally taken place to establish the facts. 

The situation may be substantially different in the “upon request” situation. Any uninsured/self-pay patient may call any provider to request a GFE for a service. And we may assume that some of these requests will be for comparing prices among providers, as was the intent of the law.  

This “shopping” situation presents some specific challenges for providers to create a GFE. Anyone, whether or not they have seen a specific provider before, may request a GFE. The requestor may or may not know the specifics of the procedure or the specific diagnosis that is generating the request.

And the vast majority of people certainly don’t know specific CPT® or HCPCS procedure codes or ICD-10 diagnosis or procedure codes. Providers and their staffs are then faced with the difficult challenge of producing the specific information required for the GFE. For example, say we have a person calling an orthopedic surgeon’s office saying they have a sore shoulder and want a GFE for a shoulder replacement. The surgeon will have no idea as to the extent of their injury or the details of the surgery necessary to correct it.

A GFE needs to be produced, but may not be very accurate or useful to the patient. This will also be an issue when individuals are comparing GFEs from different providers. If the services and diagnoses are different among the GFEs, comparison is difficult, if not useless.

The intent of the GFE provisions is noble. Prospective patients do deserve to know how much their medical services will cost before they are performed. However, the process right now has weaknesses that could be addressed. For example, providers may be able to give a range of estimates with a description, rather than a specific diagnosis and procedure code, when they have not seen the patient or have no access to the patient’s medical records. This could give patients a general idea about what they are shopping for.

Once a service can be scheduled, the provider could get more information to produce a more accurate GFE – and providers are required to do that.   

Like many new sets of requirements, we will have to see how well the GFE process works for uninsured/self-pay patients during this year. As we uncover issues, they can be reported to CMS for consideration and changes to the requirements.  

Programming Note:

Listen to Stanley Nachimson’s live report, RegWatch, today during Talk Ten Tuesdays, 10 Eastern.

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