How to get ready for good faith estimates

Navigating the ever-evolving timeline for surprise billing requirements can be daunting. 

Questions to ask

• Have you assessed your financial and operational exposure under the good faith estimate requirements? Are you complying with the provisions in effect?
• How can you build or forge partnerships with insurers, providers and tech companies to improve the consumer experience and facilitate estimating and billing?
• How can you leverage the new surprise billing rules — both GFE provisions and beyond — to strengthen your position in your local market?

On December 27, 2020, the No Surprises Act was signed into law as part of the Consolidated Appropriations Act of 2021. The No Surprises Act puts in place new information sharing requirements for both providers and payers that aim to protect patients from receiving surprise medical bills. This briefing provides a high-level overview of the new good faith estimate (GFE) requirements for self-pay and insured individuals, including the financial impact for providers. These rules require physician and health system executives to review and, when applicable, update their operational and financial processes. 

This is not just a compliance exercise, although that aspect is undeniably important. If implemented successfully, the rules offer an opportunity for providers to deliver on demands for enhanced patient experience and frictionless care delivery, better positioning themselves in the market. Ensuring a smooth scheduling and billing experience in which providers and payers work together to ensure patients have a good sense of their expected costs before the date of service can help providers compete in an increasingly dynamic market.

Understanding the GFE requirements

Under the GFE requirements, upon scheduling a service, or if requested by an individual, all state-licensed or certified health care providers and facilities now have a set number of days to send a GFE of the charges and billing codes expected to be provided as part of the scheduled visit. It’s important to remember that the “convening provider” (i.e., the provider or facility responsible for scheduling the primary items or services) also must include charges and billing codes for items or services that may be provided by other providers and facilities. Those “co-providers” or “co-facilities” must be prepared to submit related charges and billing code information to the convening provider within one business day of the request. This process looks slightly different depending on the patient’s insurance status. For example:

• For uninsured or self-pay individuals, the convening provider or facility must send the GFE to the individual.
• For insured patients, the convening provider or facility must send the GFE to the individual’s health plan. It is then the plan’s responsibility to include the GFE in an “advanced explanation of benefits.” Note: The Centers for Medicare & Medicaid Services has not yet issued regulations on the GFE process for insured individuals. Further guidance is expected.

While the process may look different, the timeline for GFE delivery, according to the law, is the same regardless of a patient’s insurance status.

Timeline for pre-service GFE delivery

GFE compliance and enforcement

The GFE provisions of the No Surprises Act took effect January 1, 2022. However, federal agencies temporarily delayed enforcement for certain parts based on an individual’s insurance status.

Enforcement timeline for GFEs

Providers and facilities that fail to meet requirements could face additional action from states or the federal government. For example, if the actual charges are at least $400 more than what is listed in the GFE sent to self-pay patients, the patient has up to 120 days of receiving the bill to challenge the amount via a selected dispute resolution (SDR) process. Providers and facilities that do not expect SDR challenges due to their patient population or policies also could face enforcement actions by state or federal agencies for noncompliance with the rules, including but not limited to civil monetary penalties of up to $10,000 per violation.

And remember, we are awaiting final rules on the insurer patient population GFE process. Therefore, it is imperative for physician and hospital leaders to ensure they are taking the appropriate steps to comply with the new rules.

Moving toward compliance

• Develop new workflows to address requests when building GFE capabilities.
• Enable care teams to provide treatment plan templates by diagnosis/procedure, which are the foundation for the GFE and billing codes
• Identify the “care period” and accounting for the other providers and facilities involved within the care period
• Build “pre-pay” capabilities to enable up-front procedure payment data mapping, with co-pay and deductible estimators, to provide a reasonable GFE

Contributing Authors:

• Heather Meade, Principal, Washington Council Ernst & Young
• David Dreher, Principal, Business Consulting, Ernst & Young, LLP
• Laura Dillon, Senior Manager, Washington Council Ernst & Young