To understand the Good Faith Estimate (GFE), let’s first dive into the No Surprises Act;
the legislation in which the GFE is found. Effective January 1, 2022, the No Surprises Act (NSA) is a collection of federal rules designed by the Department of Health and Human Services (HHS) with other federal departments to protect medical patients from surprise billing.
Specifically, the NSA protects self-pay and uninsured patients (we'll say self-pay here to refer to both) from receiving bills that are substantially more than expected. It also protects patients with insurance coverage from receiving unexpected medical bills from out-of-network (OON) facilities or providers for certain emergency or non-emergency services.
To protect self-pay patients from receiving bills for substantially more than expected, the No Surprises Act requires virtually all healthcare facilities and providers to:
Notify self-pay patients of their right to obtain a GFE of estimated costs, and...
Provide a GFE of charges to the self-pay patient before items or services are rendered.
Something to keep in mind: If the actual charges billed are $400 or more than the GFE, the self-pay patient may initiate what’s called the selected dispute resolution process (SDR) to determine what the patient must pay. For GFEs, the SDR process is also known as the patient-provider dispute resolution (PPDR) process.
Healthcare providers and facilities are currently only federally required to offer GFEs to self-pay patients in 2022; however, some states may require GFEs for insured patients (e.g., Indiana and Ohio). Check your local laws to be sure you are providing estimates compliant with your state legislation.
Post the notice “Right to Receive a Good Faith Estimate of Expected Charges” from the Centers for Medicaid and Medicare Services (CMS) in languages spoken by your patients.
Where to post: On the provider’s or facility’s website, in the office, and wherever scheduling or questions about healthcare cost occurs.
Ask patients if they are not covered by a group plan, individual health insurance, or group insurance, or federal health care program. If insured, ask if the patient does not want to submit the claim to the group plan or insurer.
Tell the self-pay patient (in the language they speak) that they have the right to a GFE upon scheduling or request.
Provide a GFE to the self-pay patient who asks about costs, requests a GFE, or schedules services.
Ensure the GFE is complete and accurate and includes all of the required elements and disclaimers.
The patient may be eligible to initiate the SDR process for incomplete or inaccurate GFEs, so it is imperative to provide new, more accurate GFEs if changes are made to planned care before services are rendered.
Provide the GFE on paper or electronically, depending on the patient’s preference, within the set time frames established in the NSA.
Every GFE needs to have the patient’s name and date of birth, the office or facility location(s), service codes, diagnosis codes, expected charges, names of providers and facilities, national provider identifier (NPI), date(s) of service(s), tax ID number, disclaimers, description of primary item or service; and an itemized list of items and services, grouped by each provider or facility.
CMS has a free downloadable template that can be utilized to stay compliant; however, Rivet’s software not only allows providers to offer clean good faith estimates for insured and self-pay patients, providers can also check eligibility, manage their payer contracts, and collect up-front payment from patients.
Below are descriptions of each data element needed and how Rivet’s software is compliant with these requirements. Click the picture for more details.
The NSA requires national drug codes (NDCs) and Rivet is currently making updates to accommodate this requirement. Currently, Rivet’s notes section can be utilized to put in NDCs.
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Situation |
Provide the GFE: |
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An item or service is scheduled 3–9 business days before the date of the item or service is rendered. |
No later than 1 business day after the date of scheduling. |
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An item or service is scheduled at least 10 business days before the date of the item or service is rendered. |
No later than 3 business days after the date of scheduling. |
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A self-pay patient requests a GFE. |
No later than 3 business days after the date of the request. |
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Changes to the original GFE are anticipated (e.g., changes to the charges, items, services, providers or facilities, etc.). |
No later than 1 business day before the items or services are scheduled to be rendered. |
Note: If changes to providers or facilities are made less than 1 business day before the scheduled item or service, the replacement provider or facility must accept the previous GFE as their GFE. Always be sure to check for any prior GFE before assuming care less than 1 business day before the scheduled item or service.
This is not a comprehensive look at all the nuances of the No Surprises Act or the good faith estimate. For more information, see CMS.gov .
Rivet’s Estimates software offers accurate good faith estimates that you can send to patients via HIPAA-compliant text and/or email, or print out the estimate right in your office. Patients will see their deductible/out-of-pocket maximum met, diagnostic codes, their financial responsibility and their plan’s financial responsibility, prior authorization flags, customized disclaimers and more.
To see Rivet's Estimates and discuss billing pain points, request a demo now.