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🇺🇸 The No Surprises Act & Good Faith Estimates

This is our best understanding of the No Surprises Act and Good Faith Estimates as of January 5th, 2022. We will continue to review available information and update this document as needed. Please don’t hesitate to reach out if you think any of the below information is incorrect or could be improved!

If you’re looking for ways to create and manage Good Faith Estimates in Jane, check out this guide!

Hey there U.S. community,

The No Surprises Act took effect in the 🇺🇸 U.S.A. on January 1st, 2022 and it sounds like it hasn’t quite lived up to its name for a lot of our practitioners. So, to help avoid any more surprises, we’ve done a deep dive on the No Surprises Act and Good Faith Estimates and summarized what we found out below.

This guide is intended for general informational purposes only and doesn’t take the place of the statutes, regulations, or formal policy guidance upon which it is based. 🤓

Let’s hop in! Feel free to click on any question you’re interested in below, or scroll through the entire guide. ⏬

What is the No Surprises Act?

The No Surprises Act was passed in late 2020 and made effective January 1st, 2022 to further protect patients from surprise medical bills for both emergency and non-emergency services. We’ll focus on how this legislation affects the latter — non-emergency services — since Jane primarily serves the non-medical community.

Under this legislation, there are new requirements that all state-licensed providers and facilities must follow when scheduling uninsured and “Self-pay” patients.

The most notable change is the requirement to provide a Good Faith Estimate in advance of scheduled services, or upon patient request, for all patients that self-pay for services (because they are uninsured or by choice). Click here to jump ahead to Good Faith Estimates. 👇

There are three other requirements that affect non-emergency services, but they are smaller in scope. We’ve listed these requirements below along with our interpretations. For more information, CMS has put together a helpful high-level overview of each of these requirements.

  1. No balance billing for non-emergency services by nonparticipating providers at certain participating health care facilities, unless notice and consent were given in some circumstances.
    • Our interpretation of what this means for most Jane clinics is that you are still able to balance bill as long as you meet the notice and consent requirements set by this act: It’s important to set financial expectations with your insurance patients if you are out of network with their health plan.
      • This statement is based on most out-of-network billing scenarios. For in-network scenarios, consult your contract with the payer as many do not allow for balance billing.
  2. Disclose patient protections against balance billing.
    • Similar to the above requirement, it’s important to make your patients aware of their protections against balance billing where applicable.
  3. Ensure continuity of care when a provider’s network status changes.
    • If you end your contractual relationship with a health plan where some of your existing patients are members, then in most cases you must:
      • Continue to accept payment from the plan at the previously agreed to rate for up to 90 days after the patient is notified of the change in the provider’s network status.
      • Continue to adhere to all policies, procedures, and quality standards imposed by the plan or issuer for such items or services as if the contract were still in place.

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Does the No Surprises Act apply to me?

The No Surprises Act applies to all state-licensed healthcare providers and facilities.

You might be asking, “What counts as a healthcare provider and healthcare facility?”. We had the same question and found an answer from CMS!

Healthcare provider: a physician or other healthcare provider acting within the scope of the practice of that provider’s license or certification under applicable State law (i.e., all practitioners operating under a state-issued license.)

  • This is what will apply to most Jane clinics

Healthcare facility: an institution in any State in which State or applicable local law provides for the licensing of such an institution pursuant to such law or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing.

  • Examples: hospitals or hospital outpatient departments, critical access hospitals, ambulatory surgical centers, rural health centers, federally qualified health centers, laboratories, and imaging centers

🗝️ Key takeaway: even if you operate a fully Cash practice (don’t bill any insurance and are nonparticipating with Medicare), you are still required to adhere to this new legislation as of January 1st, 2022 if you operate under a state-issued license or certification.

If you’re unsure if you or your practice falls under the purview of the No Surprises Act, it’s best to reach out to your State licensing body for more information.

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What is a Good Faith Estimate (GFE)?

A GFE is intended to provide uninsured or “self-pay” clients with an estimated cost of their healthcare service, prior to receiving that service. “Self-pay” clients include those who have insurance but opt not to use it to cover your services.

There are a few important things about GFEs that clinics and practitioners should know:

  1. Before your client books an appointment: they should be made aware that they have the right to receive a GFE if they are not using insurance.

  2. Before the appointment, you need to ask your clients if they’ll be using insurance: if they won’t be, you must provide them with a GFE 72 hours prior to their appointment.
    • If the appointment is booked within that 72-hour window, a GFE can be provided on the day of the appointment, at least 3 hours before the service.
  3. Delivering the GFE: a GFE should be its own document (not included within other documentation). It should be delivered in-person, by mail or via email, as selected by the client.
    • A GFE includes Patient Health Information (PHI) and therefore must be delivered in accordance with HIPAA regulations.
  4. GFEs are not contracts: a practitioner is not beholden to the estimated cost if the course of a client’s care changes, and clients are not required to complete the course of care outlined in the GFE
    • That being said, clients do have the right to dispute their bill if it is in significant excess (>$400) of what was outlined in their GFE
    • If the plan of care changes significantly from what is outlined in the GFE, the provider is responsible for providing the client with a new GFE that reflects these changes within 1 business day

Read on to see what needs to be included in a Good Faith Estimate: 👇

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What information should be included in a GFE?

  • Client name and date of birth

  • Client contact information (mailing address, phone number, and email address as available)

  • Description of the primary service/item being requested in clear, understandable language

  • An itemized list of expected services within the treatment period, including any accompanying diagnosis codes, and expected charges associated with each

  • Date the service is to be provided (if scheduled)

  • Date of GFE

  • The name and credentials (NPI and license) of all providers and/or facilities involved, along with the estimated cost of each

  • A total estimated cost

  • Practitioner signature

  • A disclaimer to inform the client that the GFE is not a contract and that the estimate is subject to change based on their course of care. Similarly, the client is not required to complete the course of care outlined in their GFE; final charges may differ from the estimate provided

Check out how you can use Jane to help manage this: 👇

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How can I create and manage GFEs in Jane?

Great question! There are a few ways that Jane can help. Check out this guide on Creating & Managing Good Faith Estimates in Jane for step-by-step instructions.

Here’s the quick version:

  • Step one: You can make clients aware of their right to a GFE by customizing the messaging on your Online Booking site or Welcome Email.

  • Step two: Ask your clients if they will be using insurance by adding a required question to your general Intake Form.

  • Step three: Build or download a GFE Chart Template, which can be added to a client’s chart, filled out, and signed.
    • We’ve added a template to the library that you can find by searching 🔎 “Jane Team- Good Faith Estimate”. Feel free to edit it to suit your practice’s unique needs!
  • Step four: Download a copy of the signed GFE Chart Entry, then upload and share it to the Files section of your client’s profile.

Important note: when you download a Chart Entry, Jane will automatically populate a lot of the information required on the GFE (client name, DOB, contact info, date created, practitioner name, etc.). You can choose to share the Chart Entry directly from the chart (without downloading it), but you will need to manually fill in all of that extra information yourself.

If you’re not sure how any of the steps above would work, please see this detailed guide for more information, or get in touch! We’re always happy to help. 😊

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Where can I learn more about the No Surprises Act and Good Faith Estimates?

If you’d like to do some more research, here are some of the resources we found really helpful:

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That’s all for this blog, folks! We hope it’s been helpful and, as always, please don’t hesitate to reach out with any questions or feedback for us.

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