The federal No Surprises Act (the “NSA”) requires all healthcare service providers to provide accurate and reliable cost estimates (good faith estimates) to patients who pay cash for services. The NSA’s good faith estimate requirement has not received the media or industry press enjoyed by balance billing bans on off-grid emergency service providers (“OON”), to OON ancillary service providers at network facilities and to OON air ambulances. vendors, but may actually be the NSA’s biggest surprise.
Specifically, the good faith estimate provision requires all health care providers and health care facilities to provide good faith estimates of “expected charges for the uninsured (or self-paid)” and inform patients of the availability of good faith estimates when scheduling a cash payment. paid or uninsured services, or at the request of a patient for cost information. 45 CFR 149.610(a)(1); 45 CFR 149.610(b)(1)(iii). The NSA defines an “uninsured or self-paid person” as (1) “a person who does not receive benefits for an item or service” under a health insurance plan; or (2) “a person who has benefits for such item or service…but does not seek to have a claim for such item or service subject to such plan or coverage.” 45 CFR 149.610(a)(2)(xiii). The provision also requires the primary service provider to obtain and submit to the patient estimates of all “co-provider” charges for services that are “ordinarily provided in conjunction with a primary item or service.” 45 CFR 149.610(b)(2); 45 CFR 149.610(a)(2)(iii).
In addition, related patient-provider dispute resolution provisions establish an enforceable patient liability mechanism for good faith estimates. The patient-provider dispute resolution process allows a patient to submit a request for independent resolution of a patient-provider payment dispute, if the final charge for items and services is $400 more than the amount listed on the good faith estimate. 45 CFR 149.620(b)(1). If the provider neglects to include an item or service in the good faith estimate, the Independent Dispute Resolution Entity may order that the patient owes $0 for the omitted items or services. 45 CFR 149.620(f)(3)(iii)(B)(1). Supplier must prove that any item or service understated or omitted from the Good Faith Estimate “reflects the costs of a medically necessary item or service and is based on unforeseen circumstances that could not have been reasonably anticipated by the provider or establishment when the good faith estimate was provided.” 45 CFR 149.620(f)(2)(i)(C). If the provider fails to present such credible evidence, the Independent Dispute Resolution Entity is required by regulation to order payment of either the amount estimated in good faith or the median amount of payments paid by insurance schemes. -sickness for the same or similar service provided in the geographic area as reflected in an independent database, or $0, depending on the circumstances. 45 CFR 149.620(f)(3)(iii). Further, the firm may not commence or continue collection efforts and must suspend the accumulation of all late fees on unpaid invoice amounts, until the dispute resolution process is concluded. 45 CFR 149.620(d)(5).
Most importantly, the Good Faith Estimate and Patient-Provider Dispute Resolution provisions apply to ALL health service providers. This includes specialties that generally do not accept insurance or operate primarily on a cash payment basis, including cosmetic surgery practices, behavioral health practices, weight loss surgeons, fertility clinics and many others.
The content of this article is intended to provide a general guide on the subject. Specialist advice should be sought regarding your particular situation.