HRS Applauds Cautious Approach to Implementation of Good Faith Estimate (GFE) Requirement for Insured Patients

December 19, 2024 – In December 2020, the No Surprises Act was enacted after years of grappling with how to address “surprise medical bills.”

While many of the provisions are directed at emergency care and services where provider choice is often limited (e.g., anesthesiology and pathology), other sections of the No Surprises Act apply more broadly and could affect electrophysiologists. As the No Surprises Act went into effect in 2022, HRS provided members with information about the provisions of the statute that could affect EP practices. One of these relevant provisions relates to the provision of good faith estimates (GFEs) to patients for scheduled care.

GFEs for Uninsured/Self-Pay Patients

As previously reported by HRS, in order to provide more price transparency and reduce the chance that uninsured patients receive “surprise bills,” the statute and regulation also introduce a new requirement for providers delivering non-emergency services to uninsured (or self-pay) individuals. (Note: a self-pay individual can be a patient who has insurance but chooses not to submit a claim to their plan). Providers must furnish a good faith estimate of reasonably expected charges to all uninsured (or self-pay) patients upon scheduling a service (unless that service is scheduled to be provided in less than 3 days) or upon request from an uninsured or self-pay individual. If you are the scheduling provider, this requirement includes reaching out to all other providers and facilities to obtain estimates for any item or service that is reasonably expected to be provided “in conjunction with“ the scheduled item or service. If you will be involved in providing a service to an uninsured or self-pay patient, but another provider or facility is responsible for scheduling that service, you should expect to be contacted with requests to provide a GFE for the charges associated with the conjunctive service. The requirement to provide the GFE to uninsured or self-pay patients was finalized with aggressive timelines, so it is important that electrophysiologists know what is required and when GFEs must be provided (either as coordinated by your practice or upon request by another provider or facility).

• A model GFE notice is available (See, Appendix 2).
• General guidance from the U.S. Department of Health and Human Services (HHS) is available here
• *NEW* CMS guidance document, What is Considered ‘Health Insurance’? Determining When Uninsured (or Self-Pay) Good Faith Estimate Rules Apply
• FAQs from the Centers from Medicare and Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight (CCIIO):
  • Uninsured/Self-Pay GFE FAQs Part 1 (December 1, 2021)
  • Uninsured/Self-Pay GFE FAQs Part 2 (April 5, 2022)
  • Uninsured/Self-Pay GFE FAQs Part 3 (December 2, 2022)
  • Uninsured/Self-Pay GFE FAQs Part 4 (December 27, 2022)
  • *NEW* Uninsured/Self-Pay GFE FAQs Part 5 (December 2024)

GFEs for Insured Patients & the Advanced Explanation of Benefits (Advanced EOB) Requirement

The No Surprises Act also included a provision that similarly requires providers to issue a GFE for scheduled care delivered to insured patients, but instead of furnishing the GFE to the patient, the GFE would be provided to the patient’s health plan to assist health plans with furnishing an Advanced Explanation of Benefits (Advanced EOB) to help patients better understand their expected out-of-pocked costs. However, because of the expected administrative burden associated with this requirement, the Departments have yet to implement or enforce this statutory provision. Continuing to express concern with how to operationalize these provisions, on December 13th, the Departments issued an update on the rulemaking schedule for these provisions, stating, “The Departments and [the Office of Personnel Management] look forward to continuing to engage with industry partners and other stakeholders as we work toward rulemaking to implement requirements for accurate and timely advanced cost estimates for consumers.”

While HRS supports cost transparency to help patients make choices and plan for the delivery of health care services, HRS also seeks to lower the administrative burden of delivering care for electrophysiologists. Therefore, we are pleased to see that the Departments are waiting to enforce these provisions in the hope that they can leverage health information technology and existing cost transparency obligations of health plans to streamline compliance with these provisions.

HRS will update members as new information on these provisions becomes available.