The Importance of GFEs (Good Faith Estimates)

Uncategorized Feb 10, 2022
 

 

A new law, now called the No Surprises Act, was passed in December of 2020 to take effect on January 1, 2022. Good Faith Estimates (GFEs) are a new requirement as of 2022 for all physician offices to offer their patients. We are going to look into these new requirements (how you can comply, what you need to do, and when you need to give this to your patients) and make it easy to understand so that you can comply with the law, which will eliminate patient complaints and lawsuits.

Why focus on the Good Faith Estimate?

The most important provision in this new law that we need to take into account is the Good Faith Estimate portion of the Act. The reason for that is twofold. First, most functional medicine providers are in physician offices in this context, so you do not have a team and you have to be the one who complies. Second, the No Surprises Act specifically excludes physician offices from its requirements. So you don't have to worry about it if you are a physician's office. However, the Good Faith Estimate part of the law has had various forms over the past few months and is the part that we need to pay closest attention to.

What is the Good Faith Estimate, and what is the requirement?

The law states that each health care provider shall furnish individuals who are not insured, or who have insurance but are not intending to seek reimbursement for the item or service, a written Good Faith Estimate of the expected charges. In Subsection (2) it states that you are to provide a notification in layman's terms of the GFE of the expected charges for furnishing the item or service. This also includes any third parties. So, if you work with labs or supplement companies, or you work with other providers who might be furnishing services, they should also include their information, including expected billing and diagnostic codes as well.

 

In simpler terms, you need to give the GFE to an individual who is not enrolled in coverage, to an uninsured or underinsured patient who is not planning to seek reimbursement. There is much legalese and obviously legislative writing in the rule that becomes legislation. So each healthcare provider must provide notification, a GFE of expected charges for the item or service, including those services or items that are not part of the primary service of, but in conjunction with, the service. If a patient is going to need other services or items related to that office visit and there's a third party involved, those items or services are reasonably expected to be provided by those third parties, along with any billing or diagnostic codes to the extent possible.

Who should you specifically give it to?

A Good Faith Estimate is to be given to individuals if they are not insured or if they intend to pay cash. However, note that if you accept insurance in your practice, you also have to give these GFEs to the insurance company (if individuals are submitting the service/items to the insurance company).

When does it need to be given?

There is a timing element, and it will be interesting to see how this is enforced for continuing care or for individuals who come in to practices quite frequently. The letter of the law says you need to give it to them at least three business days before the date of service and no later than one business day after its schedule. If I make the appointment on Monday for Friday, you need to give it to me by at least Tuesday in order to comply with federal law.

Unknown Billing Diagnostic Codes 

How are you supposed to know billing and diagnostic codes before they come in or when conditions are not yet known? This is a question on the Department of Health and Human Services FAQ, published less than 90 days ago in December 2021. The interim final rules do not require the Good Faith Estimate to include charges for unanticipated items or services that are not reasonably expected and that could occur due to unforeseen events. So if you have general protocols that you take new patients through, you might be able to start with a GFE prefilled out halfway for most patients, and then as their case progresses and you see different complexities or the way you treat that patient, the treatment plan changes based on the effects of that patient and the “care journey” that they are on. At this point,  you would just provide a new GFE. It does note that the convening provider or facility, in this case YOU, is required to provide a new GFE if you anticipate or you're notified of any changes to the scope, including changes to the expected charges, items, services, frequency, recurrences, duration, providers, or facilities. In other words, if the scope changes or there is something that you did not reasonably anticipate, you provide them with a new GFE. The timing is no later than one business day before the items are scheduled to be furnished. This timing element is a little bit more straight forward. If they have an appointment on the 24th, you have to give it to them no later than the 23rd.  I advise giving it to them on the 22nd just to be safe. Again, co-providers and co-facilities are the third parties, and if they have new information of scope or complexity that change the billing estimates, they have a duty to inform you, and then you have a duty to inform the patient as well. 

Providers are also encouraged to communicate these changes upon delivery of the new GFE, which boils down to good customer service. Here's what we're changing. Here's why we're changing it. This gives the individuals an opportunity to agree or disagree. And if they say no, then they might have to go to another clinic or another provider, but it is your job to provide these estimated changes and charges in advance.

 Note that diagnosis code means ICD codes. And service code basically means CPT codes or these other code acronyms as well. 

What needs to be in the Good Faith Estimate?

If you would rather skip further explanation and details, you can simply obtain a template from Functional Lawyer and implement it into your practice. It has all of the statutorily required and regulatory required elements in a GFE. This will save you at least an hour or more of work just from having to create your own. Or, if you want to know the details to include and create it from scratch, keep reading.

GFE Details

The following, from 45 CFR 149.610, are the content requirements of a GFE:

  • Patient name and date of birth
  • Description of the primary item or service
    • Itemized list of items or services that are reasonably expected (those items or services furnished by you, the convening provider)
    • Those items or services expected to be furnished by co-providers, third parties
  • Applicable diagnosis codes, expected service codes, and unexpected charges associated with each listed item or service (Again, you may not be able to know all of them in advance, but do your best and provide them with a GFE if it changes.)
  • Your name, National Provider Identifier and Tax ID Number, as well as the State(s) and office or facility location(s) where the items are to be furnished
  • Anything that needs to be furnished or delivered before or following the expected period of care for the primary item or service (Then you need a disclaimer as well that states separate GFEs will be issued upon scheduling or request of a list of items or services.)
  • A disclaimer that informs the uninsured (or self-pay) that there may be additional items or services throughout the course of their care
  • A disclaimer that it is only an estimate and that the charges could change
  • A disclaimer that instructs them about the dispute resolution process (So the other part of this bill is that it provides patients with a formal dispute resolution process. They can file a grievance or complaint. Then it goes in front of an adjudicator and they either side with you or they side with a patient. That is they are able to file a complaint if the actual billing exceeds the GFE by $400 or more. It is presumed that they have a right to appeal and complain and have their case heard in front of an adjudicator. )
  • A disclaimer that the GFE is not a contract (It doesn't require them to come to you for service. It is really just a menu of services, and they can select off the menu, or they can just say, “No, thanks. I'm going to go somewhere else.”)

Conclusion

As frustrating as the regulation is to comply with, it does provide a level of price transparency in the healthcare business. We've been saying for years that it's one of the only industries in America where you go and have service, not even asking for the price. And then you get a surprise bill on the back end, whether your insurance pays for it or not. You have no idea what is coming out of your pocket most of the time, and it's difficult to price shop or comparison shop. Before 2022 if you needed knee surgery, could you have called five or six orthopedic surgeons and asked them how much it would cost? Probably not. Therefore, the No Surprises Act and GFEs are good things overall. As a public policy issue, however, it can be frustrating for practice owners who have one more regulatory scheme to follow through with and comply with. But we must remember that this is part of our job and is what needs to be done.

Thankfully, we are here to help you at Functional Lawyer. If you have any questions, please reach out to us anytime.  Additionally, don't forget to subscribe to our YouTube Channel where you can receive tons more free, legal education.

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