NARHC Submits RHC Feedback on Good Faith Estimate Regulation

Sarah Hohman, NARHC Director of Government Affairs


The National Association of Rural Health Clinics submitted comments this week, shown below, in response to a request for information (RFI) issued by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury.

The RFI sought feedback regarding the impacts of the No Surprises Act, both provisions already in place, and those with delayed enforcement dates such as the co-facility/co-provider requirements expected to go into effect January 1, 2023.

We sincerely thank all of the RHCs and other stakeholders that submitted their feedback on the impacts of the Good Faith Estimate policy. Each of your perspectives allow us to further convey the administratively burdensome nature of several of these regulations and assists in explaining both the patient and provider viewpoints.

To view all submitted NARHC Advocacy Letters and Comments, please visit Please contact Sarah Hohman, NARHC Director of Government Affairs,, with any questions or concerns.

***Request for Information, Good Faith Estimate Regulation Communication***

November 15, 2022

The Honorable Chiquita Brooks-LaSure
Centers for Medicare & Medicaid Services
Attention: CMS-9900-NC
P.O. Box 8013
Baltimore, MD 21244-8013

RE: No Surprises Act Request for Information

Dear Administrator Brooks-LaSure,

On behalf of the over 5,200 Rural Health Clinics (RHCs) across the country, the National Association of Rural Health Clinics (NARHC) is pleased to submit a response to the request for information (RFI) issued by HHS, DOL and the Treasury related to various requirements of the No Surprises Act.

RHCs are part of an essential safety net of care in rural communities across the country, and for more than 40 years have been increasing care to outpatient services in medically underserved areas. RHC practitioners have long since provided individualized care to their patients, including care that is responsive to a patient’s ability to pay. While the NARHC is supportive of the positive intent behind health care price transparency provisions, we remain significantly concerned that the requirements established in the NSA are not altogether beneficial to patients nor providers.

Since initial provisions of the Good Faith Estimate (GFE) requirement went into effect on January 1, 2022, RHCs have made significant time and financial investments in becoming compliant with the policy. In doing so, providers have continuously highlighted the associated challenges and remain concerned about the increasing regulations such as the “convening provider/facility” addition to GFEs poised to go into effect January 1, 2023.

The quotes below, directly from RHCs and other stakeholders, demonstrate clinic experiences in implementing the policies, with comments coalescing firstly around staffing challenges in supporting the additional workload, specifically on an already overtaxed workforce. Providers face difficulties generating the GFEs in the limited time frames required and anticipate that this will becoming significantly more challenging and less accurate when they also need to provide service and charge information from co-providers/co-facilities. Furthermore, patient care is oftentimes outside of the scope of front office staff’s expertise, requiring the involvement of many individuals on the patient care team in the development of a GFE.

“I could easily see this role becoming a full-time position to manage both RHC and hospital estimates, especially as we are forced to include outside providers in our estimate. This piece is a huge burden. It will be very difficult to meet this requirement, especially using the current time constraints within the act.”
“The GFE requirements have placed increased administrative burden on our already taxed staffing levels. We serve all patients regardless of their ability to pay—and we draw patients from surrounding areas because other clinics in their areas do not do so. We struggle to serve our population well as regulatory burdens continue to increase. We take every opportunity to serve our patients, but in this case, the regulations give them very little benefit (if any at all) and actually take away from patient care as we have to focus on the additional requirements.

In addition, we have not had any positive feedback from patients about receiving the GFE. Most question why they are getting them and if they have to keep them. Many would prefer to not have one more paper to review and feel it is a waste of both their time and ours. In the past, the patients who were concerned about costs of clinic visits have called prior to making an appointment to get quotes. In addition, the pricing is already on our website.”

“I don’t have a single client right now, RHC or otherwise, that isn’t significantly understaffed to just provide the BASICS of a healthcare encounter. On top of that, many of them are working on smaller and smaller margins trying to cut expenses where they can because they are having to shell out major dollars to even get healthcare staff in the door to care for patients. Add on top of that all of the compliance requirements RHCs have to keep up with, some on a weekly basis, AND the ever-changing COVID landscape and state, federal, and whoever else requirements that they are trying to keep up with. People in healthcare are barely keeping their heads above water if they haven’t drowned already.”

“When first implementing the process, our administrator did all the work to make sure we had the correct information included for patients and to cover the requirement. We have trained front office staff to complete this task, but this is limited since they are not medically trained personnel and require assistance from nursing/providers to determine expected services. As a small independent RHC we have limited resources and cannot afford more robust EHR systems that might help with this task. In our area we see several cash patients on a weekly basis, and this has become an administrative as well as financial burden.

Our patients are often not educated on GFE and frequently come in trying to pay the GFE, or what they interpret as a bill from our office. In isolated rural communities there are few options available for care and patients have limited ability to “shop around” when there aren’t any other health care options within a reasonable distance.

Providing a Good Faith Estimate has increased burden on our Rural Health Clinic and created confusion for our patients. Our administrative costs associated with GFE ultimately will result in increasing our prices to compensate. It would be difficult and costly for us to try to meet the requirement of being within $400 of actual cost or to determine costs for services not provided by our clinic.”

“Since our front office is not trained in medical diagnoses and that is above their job description, we must include the nurse and sometimes the providers to make sure we are documenting the correct diagnoses and tests associated with the diagnoses.

Another complication is the distraction from patients in front of us at the clinic seeking care. With limited staff, and the time constraints on the GFE, it could lead to potential issues with patients in the clinic not getting the attention they deserve as front office staff try to complete the mandated GFEs.

As a small clinic, we cannot hire anyone else or outsource this due to a lack of resources, and it is putting a strain on our current staff. Our staff and resources are already stretched, I am not sure what will happen if we have to expand this to all patients to include 'items and services expected to be provided along with the primary items/services, even if received from another provider or facility.' It could also intimidate patients from seeking further care if they think they must have all the tests listed and will be required to pay the amount shown - even if it is just an estimate. This could cause great harm to the patient in not receiving care needed, and possibly costing taxpayers if the patient ends up in the Emergency Department due to not seeking treatment recommended.”

“The average time spent on an estimate is 15 to 20 minutes with average of 107 estimates per month. This also does not allow us to go back as frequently as we can to review the accuracy for each estimate done. As a Rural Health Clinic, we have limited staff to perform all the necessary tasks and keep compliant. If we would outsource or purchase a program to automate these services, it would affect our financial situation.

The new regulation to include Co-providers can be a liability for providers. The Co-providers could change their price and not inform the other providers. We also do not know if they offer a discount to patient, or how they access charity care.

“Reasonably expected” can be different for each patient. Healthcare is not like buying or repairing a car. Each of us have different healthcare needs and respond to drugs, tests, and treatment differently. Routine for one person may not be routine for someone else.”

“We are striving to be at 100% compliance, but personally I feel that the only way to do that is to hire a person that takes care of these to keep it consistent. That is not an option. With the upcoming regulation changes for 2023, I feel that anyone meeting 100% compliance will be impossible.”

“If the intent is to provide a menu of services and costs, the patient will ultimately receive McDonalds care. One average good faith estimate results in 15 to 20 minutes worth of work. The burden to the staff will result in a decrease in our collective abilities to take care of the patient as a whole, to provide answers to their calls, to assist them with their medications, to provide them care management services.

Ultimately the cost will push resources to the brink and likely result in many remote RHCs closing due to lack of resources. If the answer is to acquire software that automates this functionality, the same result will occur. Small RHC’s do not have the financial resources nor the staffing horsepower to manage this kind of burden.”

The National Association of Rural Health Clinics recognizes the prescriptive nature of the No Surprises Act statute but encourages CMS to use continued enforcement discretion in implementing the co-provider/co-facility and AEOB requirements. We implore the agencies to engage with stakeholders, including providers and patients, to understand and implement, within their authority, price transparency provisions that achieve meaningful transparency without significant administrative burden.

If you are interested in engaging on these impacts to safety net providers further, please contact NARHC using the information below.


Nathan Baugh                   Sarah Hohman
Executive Director                            Director of Government Affairs
NARHC                                            NARHC     
(202) 543-0348                                (202) 543-0348