No Surprise Billing Act: Ace Good Faith Estimates for Self-Pay

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No Surprise Billing Act: Ace Good Faith Estimates for Self-Pay

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No surprise billing act

The No Surprise Billing Act threw a wrench into how you bill self-pay patients and insured patients who don’t want their plan billed for services.

The law, which went into effect January 1, laid out clear – if complicated – guidelines for just what can be considered a Good Faith Estimate (GFE) for anticipated services. Your practice must comply with these guidelines when providing GFEs, or you risk hefty financial penalties – up to $10,000 per violation.

What to Include in a Good Faith Estimate No surprise billing act

To comply with the No Surprise Billing Act, your GFEs must include:

  • Basic Information: The provider’s name and NPI, patient name and date of birth, and scheduled service date must appear on the GFE.
  • Itemized Services: You must include an itemized list of expected services, with service codes (such as CPT codes); a description of the services in clear, understandable language; expected diagnosis codes; and expected charges. If more than one provider will provide care, codes, services, and charges should be grouped by furnishing provider.
  • Expected Charges: The anticipated charges must be in the cash pay rate or, if applicable, reflect any self-pay discount your practice offers.
  • Separate Services: If you anticipate additional items or services that will be separately scheduled, the GFE should indicate that. You do not need to include these charges on the GFE.
  • Disclaimers: A series of disclaimers are required to appear on every GFE:
    • The information is only an estimate of reasonably expected costs and services, and actual services and charges may vary.
    • The patient has the right to dispute the bill if they’re charged more than what’s listed on the GFE as part of the patient-provider resolution process. You must include instructions on where patients can find information about your practice’s patient-provider resolution process and that initiating the process will not adversely affect treatment quality.
    • The GFE is not a contract and doesn’t require the patient to obtain services from your practice.

You must provide a patient with a copy of their GFE, either a printed copy or an electronic copy that can be printed or downloaded so they can retain it for their records.

When to Send a Good Faith Estimate

When you are required to prepare and send a GFE depends on how far out a patient’s services are scheduled.

  • More Than 9 Business Days in Advance: For services scheduled more than nine business days in advance, you must deliver a GFE within three business days of scheduling.
  • Between 3 and 9 Business Days in Advance: If a service is scheduled between 3 and 9 business days in advance, you must provide the GFE no later than the business day after scheduling.
  • Fewer Than 3 Business Days in Advance: You are not required to provide a GFE for services scheduled fewer than three business days in advance unless the patient requests one.

Note: You also must provide a GFE upon request even if you’re not yet scheduling a patient’s service. Any questions you receive from patients about the cost of services should be treated as a request for a GFE and one must be prepared.

The No Surprise Billing Act isn’t the only thing that’s made your billing process confusing. New balanced billing laws control what you can and cannot write off and getting it wrong could mean criminal prosecution. Avoid running afoul of balanced billing laws with the step-by-step expert advice in Healthcare Training Leader’s online training session, Stop Huge Penalties for Innocent Balanced Billing Law Violations. In this 60-minute training, Heidi Kocher, BS, MBA, JD, CHC, walks you through the steps you need to take to ensure you’re billing correctly so you don’t find your practice in legal trouble. Access this valuable training today!


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