Read this if you work for a healthcare organization that serves uninsured or self-pay patients.
The No Surprises Act was passed in 2020 as part of a COVID relief package, with the goal of reducing surprise bills for patients who received medical or surgical services. One part of the act requires healthcare facilities and providers to give Good Faith Estimates (GFEs) to uninsured and self-pay patients starting on January 1, 2022. Read on for frequently asked questions about this topic, an update for 2023, and resources where you can find more information.
Frequently asked questions about good faith estimates for healthcare
What is a good faith estimate?
A Good Faith Estimate (GFE) is a document provided to a patient that details the expected charges for healthcare services provided. It is not a bill.
Who needs to provide GFEs, and to whom?
At this time, GFEs need to be provided to uninsured and self-pay patients.
The following healthcare facilities must comply:
- Federally Qualified Health Centers (FQHCs)
- FQHC Look-Alikes
- Tribal/Urban Indian Health Centers
- Rural Health Clinics (RHCs)
- Hospitals
- Hospital outpatient departments
- Critical access hospitals
- Title X Family Planning Clinics
- Health care providers who serve uninsured and self-pay patients
How should information about the GFE process be communicated to uninsured and self-pay individuals?
Information about the availability of GFEs for uninsured or self-pay individuals must be:
- Written in a clear and understandable manner and prominently displayed:
- On the facility’s website and easily searchable from a public search engine
- In the office (such as in the patient waiting room), and
- Onsite where scheduling or questions about the cost of items or services occur, such as at the registration or check-out areas
- Explained verbally when scheduling an item or service or when questions about the cost of items or services occur
- Made available in accessible formats, and in the languages spoken by individuals considering or scheduling items or services
How does the US Department of Health and Human Services (HHS) define uninsured and self-pay individuals?
HHS has a two-fold definition:
- Individuals who have no health insurance coverage
- Individuals who do have health insurance coverage, but do not want to have a claim submitted to their insurer
Both of these groups of individuals must receive a GFE.
What content is required in a GFE?
A GFE must include the following:
Patient information
- The patient’s name and date of birth
Services estimated
- A description of the primary item or service in clear and understandable language and, if applicable, the date the primary item or service is scheduled
- A list of items or services reasonably expected to be furnished for the primary item or service
Information about services, providers, and estimated charges
- Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service
- The name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the GFE, and the State and office of the facility’s location where the items are services are expected to be provided
- Lists of items or services that the provider or facility anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service. (A disclaimer should state that separate GFEs will be issued upon scheduling or upon request of the listed items or services.)
Disclaimers
- A disclaimer that there may be additional items or services that the provider or facility recommends as part of the course of care that must be scheduled or requested separately and are not included in the GFE
- A disclaimer that the information provided in the GFE is only an estimate and that actual items, services, or charges may differ from the GFE
- A disclaimer that the individual has a right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the GFE.
- “Substantially in excess” is defined as at least $400 more than the total amount of expected charges.
- This disclaimer must include instructions about where an uninsured or self-pay individual can find information about how to initiate the patient-provider dispute resolution process and state that the initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services that are furnished.
- HHS strongly encourages providers and facilities to include an email address and telephone number for someone within the provider’s or facility’s office that has the authority to represent the provider or facility in a billing dispute.
- A disclaimer that a GFE is not a contract and does not require the uninsured or self-pay individual to obtain the items or services identified in the GFE.
HHS encourages sliding fee discount providers and facilities to include information about the provider’s or facility’s sliding fee schedule and any other financial protections that it offers. Sliding fee discount providers and facilities have flexibility to determine how best to demonstrate the expected charges associated with each listed item or service, and to determine what additional information to include, if any.
What are the required methods for providing a GFE?
A GFE must be provided in written form either on paper or electronically, based on the individual’s requested method of delivery and within the required time frames. GFEs that are provided electronically must be provided in a manner that the individual can both save and print. A GFE must be written using clear and understandable language that can be understood by the average uninsured or self-pay individual.
If the individual requests a GFE in a method other than on paper or electronically (such as by telephone or verbally in person), the provider or facility may verbally inform the individual of the information contained in the GFE. However, the provider or facility must also issue the GFE in written form.
What is the timeline for providing a GFE?
When providing a GFE to an uninsured or self-pay patient, the following time frames must be followed.
When the service is scheduled: |
When the GFE must be provided: |
If scheduled at least 3 business days prior to the date that the item or service will be furnished |
Not later than 1 business day after the date of scheduling |
If scheduled at least 10 business days prior to the date that the item or service will be furnished |
Not later than 3 business days after the date of scheduling |
Please note, when a GFE is requested by an uninsured or self-pay patient, a GFE must be provided not later than 3 business days after the date of the request.
How long should a provider or facility retain a copy of GFEs?
A GFE is considered part of the patient’s medical record and must be maintained in the same manner. At the request of an uninsured or self-pay individual, the provider or facility must provide a copy of any previously issued GFE within the last six years.
Update for 2023
- As of the start of 2023, all of the preceding requirements remain in place.
- As of January 1, 2023, HHS has paused enforcement on the next phase of GFE implementation
The next phase of GFE implementation, which began on January 1, 2023, requires that GFEs for uninsured and self-pay patients include expected charges from co-providers or co-facilities that are part of an episode of care for a patient coordinated by a provider or facility. However, on December 2, 2022, HHS paused its enforcement of this requirement based on comments it received during the rulemaking process indicating that compliance with this provision was likely not possible by January 1, 2023.
HHS is extending enforcement discretion, pending future rulemaking, for situations where GFEs for uninsured or self-pay individuals do not include expected charges from co-providers or co-facilities. We will provide an update when HHS issues any communication about changes to GFE-related enforcement.
Helpful resources for FQHC, RHCs, and other healthcare facilities
If you have questions about the information provided in this article or are interested in an external review of your healthcare facility’s compliance with current GFE requirements, please contact Robyn Hoffmann or Mary Dowes.