The No Surprises Act (NSA) is a new federal law that exists to protect patients from unexpected medical bills for out-of-network expenses. As of January 1, 2022, healthcare providers, medical facilities and service plans can no longer balance-bill patients for non-emergency, emergency or air ambulance services.

The new law applies to patients under a group health plan, group or individual health insurance coverage. When patients opt to self-pay or do not have insurance, the NSA dictates that practitioners must provide a Good Faith Estimate (GFE) prior to undertaking an appointment or any treatment for such patients. We’re breaking down the GFE requirement and explaining how your practice can ensure compliance moving forward.

A Summary of the Good Faith Estimate as Required by the No Surprises Act

The GFE provision states that providers must issue a GFE of the expected charges that clearly outlines a patient’s billing protections and estimated costs before any appointment. This way, new (and continuing) patients do not receive surprise bills for medical services without prior knowledge.

For example, if a patient is billed for an amount that exceeds the estimate by $400, the patient can file for Patient-Provider Dispute Resolution with the Health and Human Services Department (HHS) for a small administrative fee. Then a certified third party, certified by HHS, will analyze the disputed claim, and determine the correct payment amount.

Which healthcare providers are subject to the Good Faith Estimate requirement of the No Surprises Act? 

The No Surprises Act and the GFE requirement apply to all healthcare providers, service plans and medical facilities operating under any state-issued license or certification. So far, there are no exemptions based on specialty. In other words, it applies to all medical practices, regardless of the type of service, including physicians’ offices, hospitals, and behavioral and mental health providers.

Which patients should receive a GFE?

The cost estimation requirement is applicable to any patients without insurance or who opt to self-pay (proceed without billing their insurance company). If an insured patient requests one, providers can send it to their health insurance company.

However, the NSA and GFE requirements do not apply to patients covered under federal healthcare programs like Medicare, Medicaid or TRICARE. They also do not apply to emergency services, except air ambulance services, since these appointments are not scheduled in advance.

How to provide a Good Faith Estimate that is compliant with the No Surprises Act.

Conduct real-time insurance verification.

The first step in delivering an NSA-compliant estimation is to accurately determine whether a patient has insurance and if the services you provide are eligible for coverage. ClearGage’s treatment cost estimator offers real-time insurance verification, which enables you to accurately determine which patients require an estimate before their appointments.

Provide an accurate cost estimate for self-pay and uninsured patients.

According to FederalRegister.gov, all Good Faith Estimates must include the following:

• “Patient name and date of birth;
• An itemized list of items or services expected to be provided by the co-provider or co-facility that are reasonably expected to be furnished in conjunction with the primary item or service as part of the period of care;
• Applicable diagnosis codes, expected service codes and expected charges associated with each listed item or service;
• Name, NPI and TIN of the co-provider or co-facility and the state(s) and office or facility location(s) where the items or services are expected to be furnished by the co-provider or co-facility;
• A disclaimer that informs the uninsured (or self-pay) individual of their right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the good faith estimate, as specified in 45 CFR 149.620; this disclaimer must include instructions for where an uninsured (or self-pay) individual can find information about how to initiate the patient-provider dispute resolution process and state that the initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to an uninsured (or self-pay) individual by a provider or facility; and
• A disclaimer that the good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate.”

Our treatment cost estimator provides many of the above in real-time, thus enabling providers to quickly create accurate cost estimates for uninsured and self-pay patients prior to any appointments.

What are the penalties for failing to provide a GFE?

Failure to comply with the No Surprises Act and its cost estimation requirement will result in penalties from both state and federal governments. Your practice may encounter fines of up to $10,000 per penalty. In addition, you could be subject to a drawn-out dispute process to settle the claim.

Ready to learn more?

The ClearGage treatment cost estimator was designed with both patients and providers in mind. You can use this tool to effortlessly complete both processes listed above while empowering your patients with accurate cost estimations that are customizable and HIPAA compliant.

To see our platform in action, just contact us and fill out the request form.