How do you comply with the No Surprises Act’s Good Faith Estimate (GFE) requirement if you’re a Federally Qualified Health Center (FQHC) or a provider or facility that offers sliding fee discounts? The Centers for Medicare & Medicaid Services (CMS) provided the following guidance on December 27, 2022.
Federal law generally requires providers and facilities to provide a GFE that includes “a description of the primary item or service; an itemized list of items or services, grouped by each provider or facility, reasonably expected to be furnished in conjunction with the primary item or service for that period of care; applicable diagnosis codes; expected service costs; and expected charges associated with each listed item or service” upon request or when scheduling an item or service at least three business days in advance. Further, “the expected charges must reflect any discounts.”
The Department of Health and Human Services (HHS) “recognizes that FQHCs and other providers and facilities face unique challenges in meeting these requirements.”
HHS will consider providers and facilities that offer sliding fee discounts based on income and family size in compliance with GFE requirements for uninsured and self-pay individuals in the following situations:
New Patients: Providers and facilities that do not know the expected charges associated with each item or service because they lack sufficient information about income or family size when an item or service is scheduled must, at a minimum, list undiscounted prices. Providers and facilities that take this approach should include information about their sliding fee schedules and other financial protections they offer, such as a copy of the sliding fee schedule and a statement that patients are not denied service based on inability to pay even if this means reducing or waiving costs. Providers and facilities may demonstrate expected charges with a schedule of expected charges based on income and family size. These examples are not exhaustive. Providers and facilities have flexibility with respect to determining how best to demonstrate expected charges and determining what additional information to include, if any.
Established Patients: An uninsured or self-pay individual’s income or family size may change between the initial financial counseling session and subsequent visits. Providers and facilities may rely on the income and family size information on file to generate an “established patient” GFE or they may generate “new patient” GFEs that list undiscounted prices. Providers and facilities are in the best position to determine which GFE is appropriate based on their internal sliding fee discount policies. However, they should include a disclaimer that the GFE is based on financial information on file and that actual charges may differ based on changes in an individual’s financial circumstances.
Patient–Provider Dispute Resolution Process: An uninsured or self-pay individual with a new patient GFE may initiate the patient-provider dispute resolution (PPDR) process if the bill is at least $400 more than the undiscounted price listed in the GFE. An uninsured or self-pay individual with an existing patient GFE that is consistent with the good faith requirements as prescribed in 45 CFR 149.610 may institute the PPDR process as discussed in this section and 45 CFR 149.620. Sliding fee discount providers and facilities may provide all uninsured or self-pay individuals with GFEs in accordance with 45 CFR 149.610.
HHS encourages states that are primary enforcers of GFE requirements to take a similar enforcement approach and will not determine that a state is failing to substantially enforce the requirement if it does so. HHS recognizes that most providers and facilities that don’t expect to bill uninsured or self-pay individuals have limited resources to provide individualized GFEs to patients they don’t expect to charge.
Providers who do not expect to bill uninsured or self-pay individuals for scheduled or requested items or services can comply with GFE requirements under the following conditions if they meet all other requirements of 45 CFR 149.610:
- They provide an abbreviated GFE
- They do not bill individuals who receive an abbreviated GFE provided they meet all other requirements of 45 CFR 149.610
- No items or services in the abbreviated GFE are expected to be furnished by co-providers or co-facilities in conjunction with the primary items or services
The abbreviated GFE must include the following elements:
- Patient name and date of birth
- Provider or facility’s name National Provider Identifier (NPI), Taxpayer Identification Number (TIN), and the state(s) and office or facility locations where items or services are expected to be furnished
- If scheduled, the date(s) items or services are scheduled to be furnished
- A statement that the provider or facility will not bill the individual for any items or services furnished on the scheduled date(s) or for nonscheduled items or services being furnished upon request and the GFE is being provided upon request
- A disclaimer that informs individuals of their right to initiate the PPDR process if actual billed charges are $400 or more, instructions about how to initiate the PPDR process, and states that initiation of the PPDR process will not affect the quality of health care services provided
- A disclaimer that the GFE is not a contract and it does not require the individual to obtain items or services from any providers or facilities listed in the GFE
- A disclaimer that informs the individual that the convening provider or facility may recommend additional items or services as part of the course of scheduled or requested care
Providers and facilities that provide an abbreviated GFE may be subject to the PPDR process if they bill $400 or more for items or services furnished on the expected date(s) of service included in the abbreviated GFE. Any items or services furnished are applicable because the abbreviated GFE does not list specific items or services.
HHS strongly encourages providers and facilities to include an email address and telephone number for someone within their office or organization such as a medical billing specialist, general counsel, or compliance officer who has the authority to represent the provider or facility in a billing dispute to facilitate communication with the Selected Dispute Resolution Entity (SDRE).