We’re getting closer to the effective date of the No Surprises Act, January 1, 2022. As part of this Act, “good faith estimates” are required of providers. But what does this mean exactly?

Firstly, good faith estimates are required for uninsured individuals or self pay individuals. When a provider finds out that an individual is uninsured, they must provide an estimate of expected charges. By “uninsured” or “self pay”, the individual either has no benefits or has benefits but does not want to have a claim submitted to their insurance plan for the service.

These good faith estimates tell the individual what they can expect to pay for the services. This not only includes the primary service, but also other services such as those performed by other providers or facilities. It is an amount that is to be reasonably expected.

What’s Included In The Good Faith Estimate?

The Centers for Medicare and Medicaid Services gives the example of a surgery. If an uninsured patient goes through surgery, the good faith estimate would need to include the fee for the surgery itself, labs, tests, anesthesia, etc. These are services that are used in the surgery that are not the actual main operation itself. These would all need to be included in the estimate, along with the surgery cost. However, services that are scheduled separately, such as pre-surgery appointments, do not need to be included in this estimate.

With consideration to the fact that it will take time for providers to develop a system where they can provide these estimates to patients, especially considering that some of the fee estimates may include costs of other providers or facilities involved in the patients’ care, the US Department of Health & Human services will exercise their discretion in enforcing this in cases where the estimate does not include services by other providers. This discretion will be exercised for good faith estimates provided between January 1, 2022 and December 31, 2022.

Good Faith Estimate Disputes

Providers and facilities will also need to be aware of the dispute process for good faith estimates. In situations where the fee that patients are billed is significantly higher than what the good faith estimate was, a patient-provider dispute process can be carried out to settle the payment amount.

Eligibility is granted if the patient received a good faith estimate, if the process is started within 120 days of the patient receiving the bill, and if the billed amount was at least $400 more than the good faith estimate listed for any providers and facilities on the estimate.

Therefore, as healthcare provider or facility, it is important that you put processes in place to be able to, as correctly as possible, calculate the good faith estimates for patients. This can not only help your facility avoid payment disputes and be in accordance with the No Surprises Act, but it can also help put patients’ minds at ease about payments, helping the patient experience.

At Americare Network, we keep up-to-date with everything in the medical billing industry. Contact us today to learn more about how we can help with your facility’s medical billing.