Good Faith Estimate Resources

The Good Faith Estimate (GFE) provisions of the No Surprises Act (NSA) apply broadly to all healthcare facilities and providers, including RHCs. For additional background, please review NARHC’s December 2021 and December 2022 webinars here.

Beginning January 1, 2022

Requirements

• Facilities are required to post notices alerting self-pay and uninsured patients of their right to obtain a GFE. These must be posted on the provider’s website as well as in the facility wherever scheduling and questions about cost of items/services may occur.
  • Sample: Notice of GFE Availability
• Facilities are required to provide GFEs to uninsured and self-pay patients who either request the summary of charges and automatically upon the scheduling of an appointment. Note: this does not apply to Medicare, Medicaid, Veterans Health Insurance, and other such Federal programs. Scheduling staff should be trained to ask the following questions when a patient schedules an appointment 3 or more days in advance:
  • Do you have insurance coverage? If no, GFE must be issued. If yes:
    • Do you wish to have a claim submitted to your insurance for this visit/services? If no, GFE must be issued. Note: this would be an unexpected question for most patients, and unlikely that the facility will generate many GFEs for this category of patients. It is critical that these questions are explicitly asked (either by a scheduler or via online scheduling portal) and that communications are appropriately documented. If the patient wishes to have a claim submitted to their insurance, the facility is not required to generate a GFE.
• Good Faith Estimates must be provided to the eligible patient on the timeframe shown below. Therefore, GFEs would not be required for walk-in services, emergency care, etc. that are unscheduled.

• GFEs must include (Sample: Good Faith Estimate Template). Please note: the sample includes template forms for co-providers/facilities in addition to the convening provider. These charge estimates were required to be included beginning January 1, 2023; however, these additional requirements have been delayed indefinitely. See below for additional details):
  • Patient name and date of birth
  • Description of the primary item or service (plus date scheduled, if applicable)
  • Itemized list of items and services reasonably expected to be furnished by convening provider in that “period of care”
    • This may include encounters, procedures, tests, supplies, prescription drugs, other fees associated with providing care, etc. "Reasonably expected" and "period of care" carry a significant amount of weight in this policy. Ensure that your documentation supports how your staff carries out these requirements.
  • Service codes: CPT, DRG, HCPCS, or NDC
  • Diagnosis codes (not required unless necessary for calculation of the GFE)
  • Expected charges associated with each item/service
    • Expected charge is defined as “the cash pay rate or rate established by a provider or facility for an uninsured (or self-pay) individual, reflecting any discounts for such individuals…
    • RHCs that offer fee scales to their patients should review CMS FAQ #4.
  • Name, address, TIN, and NPI of provider/facility
  • List of items/services that may be reasonably expected within the period of care but would require separate scheduling
    • This list is not required to include expected charges as those would be provided upon scheduling of the additional appointments/services
• GFEs must also include the following disclaimers (Sample: Disclaimer Template)
• The GFE is an estimate and subject to change
• There may be additional items or services recommended by the provider not contained in the GFE
• Patients have the right to initiate the patient-provider dispute resolution process
• The GFE is not a contract

*GFEs must be issued either electronically or on paper to the patient following the timeframes above. GFEs must be kept in the patient’s medical record for at least 6 years. There is not a requirement that the patient must sign the GFE or otherwise acknowledge receiving it, however this may be useful for tracking purposes.

*While many facilities already publicly list self-pay pricing and that transparency is likely beneficial to their patients, that does not meet the requirements established by this law.

Enforcement

• The primary enforcement mechanism is through a patient-initiated dispute resolution process.
  • If after receiving a bill, the patient realizes they have been billed for an amount that’s $400 more than what was included on the GFE, they can request that an independent third-party, review the case and determine an appropriate payment.
    • Patient must initiate the process online, possess a copy of the GFE, and pay a non-refundable $25 fee.
    • During this process, the patient and provider can separately resolve the dispute.
• Additionally, the No Surprises Act includes language on failure to comply with its regulations including that states have “primary responsibility” for enforcement; however, HHS has the authority to require a corrective plan and/or monetary penalties (up to $10,000 per violation).
• Significant responsibility lies with the scheduling staff at the time of the initial conversation with the patient, or in your patient portal scheduling tool, depending on how patient visits are scheduled, in order to generate the information required to create a GFE. GFEs are to be based on the information the RHC has at the time the GFE was requested, not account for unanticipated care. In the event the patient initiates the dispute resolution process, the provider will have the opportunity to dispute why the additional charges were for medically necessary services and were unanticipated at the time of scheduling.

Beginning January 1, 2023 - CMS has delayed these additional provisions set to kick in 1/1/2023 pending future rulemaking. The Advanced Explanation of Benefits (AEOB) provision of the No Surprises Act also does not yet have an effective date.

Requirements

• The current requirements continue, and in addition, the convening provider, i.e., the RHC, is also responsible for including co-provider/co-facility services and charges (where other reasonably expected services may be provided within the same period of care) on the same GFE.
  • Intended to provide the patient “a full picture of the cost of a particular medical event.”
• This co-provider/co-facility section of the GFE must include:
  • Patient name and date of birth
  • Itemized list of items/services reasonably expected to be furnished in conjunction with the primary item/service during the period of care
  • Service codes: CPT, DRG, HCPCS, or NDC
  • Diagnosis codes (not required unless necessary for calculation of the GFE)
  • Expected charges with each item/service
  • Name, address, TIN, and NPI of provider/facility
  • Disclaimer that the GFE is not a contract
• CMS explains that “no later than one business day after scheduling the primary item or service or receiving a request for a GFE, the convening provider or facility must contact all co-providers and/or co-facilities that will provide items or services in conjunction with the primary items or services and request GFE information including the expected charges for these items or services expected to be provided by the co-provider or co-facility.” Co-providers then have only one day to provide that information to the convening provider. In the event that this information is not provided by co-providers, ensure this is documented.

Additional Resources:

• Regulation
• CMS Webinar
• Patient Initiate Dispute Resolution Process
• CMS FAQ 1
• CMS FAQ 2
• CMS FAQ 3
• CMS FAQ 4
• NARHC Webinars

Please contact Sarah.Hohman@narhc.org with questions.