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The new year brings new requirements on health care providers. One new requirement is contained in the federal No Surprises Act. Under the Act, providers are required to provide “good faith estimates” for service charges to patients prior to an appointment and upon request. Specific requirements include the following:

  • Notice on Right to Receive a Good Faith Estimate: Providers must provide patients with a notice that informs them of their right to receive a good faith estimate of charges. The notice should be posted on the provider’s website, in the provider’s office, and where scheduling or questions about the cost of health care occur.
  • Coverage Determination: Providers need to ask each patient who schedules services if the patient has any health insurance coverage (including government insurance programs like Medicare, Medicaid, or Tricare), and, if so, whether the patient intends to submit a claim to that insurance for the service. The good faith estimate procedures below only apply if a patient is not covered by insurance and/or does not intend to submit a claim to the patient’s insurance.
  • Good Faith Estimate: Providers need to provide a good faith estimate of charges to every self-pay or uninsured patient who: (1) requests an estimate of charges, (2) discuss or inquire about potential costs of items or services, or (3) schedules services with the provider. The content of a good faith estimate must include the following:
    • Patient’s name and date of birth;
    • Description of the primary item or service in clear and understandable language (and if applicable, the date the primary item or service is scheduled);
    • Itemized list of items or services reasonably expected to be furnished for the primary item or service;
    • Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;
    • Name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the good faith estimate, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility;
    • A disclaimer that informs the patient that there may be additional items or services the provider recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate;
    • A disclaimer that informs the patient that the information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the patient and that actual items, services, or charges may differ from the good faith estimate;
    • A disclaimer that informs the patient of the patient's 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; and
    • A disclaimer that the good faith estimate is not a contract and does not require the patient to obtain the items or services from any of the providers or facilities identified in the good faith estimate.

The deadlines for providing a good faith estimate are the following:

    • If the appointment is scheduled 3-9 business days before the appointment date, provide the estimate no later than 1 business day after the date of scheduling;
    • If the appointment is scheduled 10 or more business days before the appointment date, provide the estimate no later than 3 business days after the date of scheduling; or
    • If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), provide the estimate no later than 3 business days after the date of the request.

Please note that the good faith estimate procedures will be expanded to insured patients at a later date.

If you would like more information about the No Surprises Act requirements, please contact Casey Moriarty, Lee Kuo, or Maddie Haller.