No Surprises Act: What Providers Need to Know

The No Surprises Act, implemented at the beginning of 2022, aims to protect patients from receiving “surprise” medical bills when they receive 1) emergency healthcare services or 2) non-emergency healthcare services from out-of-network providers at in-network facilities.  

Of course, the terminology “out-of-network” and “in-network” refer to insurance coverage, but there are also requirements under the No Surprises Act that apply to self-pay patients. A self-pay patient is someone who either does not have health insurance or does have health insurance but does not plan to bill insurance for the services.  

The Good Faith Estimate 

If a self-pay patient seeks out healthcare services from a provider, the provider must notify them that they are entitled to what is called a Good Faith Estimate (GFE) of the cost of the expected services.  

The provider must notify the patient of the availability of a GFE in three ways:  

  1. In a written document that is clear, understandable, and prominently displayed (in the office, on the provider’s website)  
  2. Verbally when the services is scheduled or when the patient inquires about the cost of the service; and  
  3. Make the notification available in accessible formats, and in the language(s) spoken by the patients.   

CMS has published a compliant notice providers may use in their office and on their website.  

Request for a Good Faith Estimate 

The timeline in which the provider has to provide the GFE is determined by the date of request or the date the appointment is scheduled. There is no ability of a patient to “waive” his or her right to a GFE,  

If no appointment is scheduled and the patient requests a GFE, the provider must provide the GFE within 3 days of the request 

If the patient makes an appointment more than 10 days in advance, the provider must provide the GFE within 3 days of the appointment being scheduled.  

If the patient makes an appointment 3-10 days in advance, the provider must provide the GFE within 1 day of the appointment being scheduled.  

Requirements of the Good Faith Estimate 

The GFE must include the following:  

  1. Patient’s name and date of birth;
  2. Clear description of the service and the date the appointment is scheduled for (if applicable); 
  3. List of all items and services (including those to be provided by co-providers); 
  4. CPT code, diagnosis code, and charge per item of service; 
  5. Name, NPI, and TIN of all service providers and the state where the services will be rendered; 
  6. List of items from other providers that will require separate scheduling; 
  7. Disclaimer that separate GFEs will be issued upon request for services listed in number 6, and that items in number 4 will be provided in those separate GFEs; 
  8. Disclaimer that there may be other services required that must be scheduled separately during the course of treatment and are not included in the GFE; 
  9. Disclaimer that this is only an estimate and actual services, and charges may differ; 
  10. Disclaimer informing the patient of their rights to a patient-provider dispute resolution process if actual billed charges are substantially above the estimate, as well as where to find information on how to start the dispute process; 
  11. Disclaimer that GFE is not a contract, and the patient is not required to obtain services from the provider. 

A new GFE should be provided to the patient as new information becomes available or new services are expected. If a treatment plan is ongoing for more than one year, a new GFE should be provided to cover the following 12 months. 

While no specific form is required, CMS has published a compliant form for providers’ use.  

Actual Charges Exceed the Good Faith Estimate 

A GFE does not guarantee a certain price. However, if the billed charges exceed the charges for services listed in the GFE by $400 or more, the patient may engage in a dispute resolution process with the provider.  

What Providers Must Do Now 

Providers must begin complying with the No Surprises Act and the Good Faith Estimate requirement immediately. First, providers should post a notice in the office and on its website that a GFE is available for self-pay patients. Personnel handling scheduling and intake calls should also be trained in notifying self-pay patients about the availability of a GFE.  

Next, providers should create a form GFE (or use the form provided by CMS) that can be filled out for each self-pay patient and provided in a timely manner as required by the rule.