January 24, 2022
Area(s) of Interest:
Out of Network Billing
The Centers for Medicare and Medicaid Services (CMS) recently published an FAQ about the good faith estimate (GFE) requirement under the federal No Surprises Act (NSA), which went into effect on January 1, 2022.
Under the NSA, providers and facilities that schedule items or services for uninsured or self-pay patients must comply with the NSA’s good faith estimate requirement. (A self-pay patient meaning an individual that has coverage but chooses not to use their benefits.)
The FAQ—Frequently Asked Questions (FAQs) about Consolidated Appropriations Act, 2021 Implementation- Good Faith Estimates— clarifies, among other thing, that the requirement applies to all providers and facilities, not just those who are out-of-network. Therefore, for example, if an insured patient chooses to pay cash for a service or is seeking to schedule a non-covered service, the NSA’s requirement to provide a good faith estimate would still apply.
The FAQ further states that no specific specialties, facility types or sites of service are exempt from this requirement.
Providers must provide the good faith estimate within 3 business days of scheduling the services if the service is scheduled 10+ business days in advance (or within one business day of scheduling, if scheduled at least three but not more than 10 business days in advance) or upon request by an uninsured or self-pay patient. It there are multiple providers involved in a procedure, the “convening” provider must obtain estimates from all providers. CMS has said it will exercise enforcement discretion for the first year when co-providers are involved.
CMA opposed many aspects of the GFE provision because it is extremely burdensome and the timelines are unrealistic; therefore, CMA is concerned it will discourage physicians from caring for the uninsured. CMA continues to advocate for this and other changes the law.
To help physicians understand their rights and obligations under the NSA, the California Medical Association (CMA) has published an overview, “The No Surprises Act: What Physicians Need to Know.” The document is available to members-only.
CMA also recently hosted a one-hour webinar that discussed the impact of the No Surprises Act on physicians in California, including the interplay with AB 72 and other California-level surprise/balance billing protections. The webinar is now available for on-demand viewing.
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