Effective across the U.S. since Jan. 1, 2022, the No Surprises Act establishes federal protections against surprise medical bills, which occur when consumers receive care from out-of-network doctors, hospitals, and other healthcare providers.
One of the most important parts of the No Surprises Act is the good faith estimates (GFE) provision. This provision requires healthcare providers to make comprehensive GFEs of charges for services and items provided to uninsured patients and self-pay insured patients who do not want to submit claims to their insurers. GFEs are notifications that outline uninsured or self-pay individuals' expected charges for a requested or scheduled service or item. It should include primary services and items as well as items and services reasonably expected to be provided, even if the patient will receive the services and items from another facility or provider.
Read this guide to learn more about the No Surprises Act and good faith estimate requirements. Along the way, we will discuss who must comply with the No Surprises Act's GFE requirements, who receives GFEs, whether you can issue a single estimate for recurring services, time frames for providing GFEs to individuals, rules for changing GFEs, GFE disclosure requirements, GFE regulations for co-providers, and more.
Every healthcare provider must comply with the No Surprises Act's GFE requirements. For the purposes of the GFE, a healthcare provider means a physician or another type of provider acting within the practice scope of their certification or license, including providers of air ambulance services.
Additionally, every healthcare institution licensed under applicable local or state law as a healthcare facility must comply with the No Surprises Act's GFE requirements. Examples include:
To determine whether someone needs a GFE, ask them whether they are enrolled in:
If the individual is not enrolled in any of these, they are considered uninsured, and you must give them a GFE.
If they are enrolled in one of the above, ask them whether they are submitting a claim. If not, the individual is considered self-pay and must receive a GFE.
Yes, you can issue a single estimate for recurring primary services or items if both of the following requirements are met:
After receiving a GFE request from an uninsured or self-pay individual or scheduling a primary service or item for such an individual, you must contact all co-facilities and co-providers who are reasonably expected to provide services or items in support of or in conjunction with the primary service or item, no later than one business day after receiving or scheduling the request.
Note that you must request the co-facilities and the co-providers to submit GFE information to you. The request should have the date by which you must receive the GFE.
You also need to provide a GFE to an uninsured or self-pay patient within the following time frames:
The U.S. Department of Health and Human Services recognizes that some facilities or providers may need to establish secure and efficient communication channels for sending GFE information between convening facilities or providers and co-facilities and co-providers. HHS also understands that it may take time for facilities and providers to create reliable processes and systems for providing and receiving GFE information from co-facilities and co-providers.
Accordingly, from Jan. 1, 2022, to Dec. 31, 2022, HHS will exercise enforcement discretion when facilities and providers send GFEs to insured or self-pay individuals that do not include expected costs from co-facilities co-providers.
Note that a co-facility or co-provider is not prohibited from furnishing GFE data before Dec. 31, 2022. The self-pay or uninsured individual can separately request a GFE directly from the co-facility or co-provider. In such a case, the co-facility and co-provider would be required to provide the GFE for the services or items.
Generally speaking, the HSS encourages providers and convening facilities to include a range of expected charges for services and items reasonably expected to be billed and provided by co-facilities and co-providers. It also encourages states to take similar approaches and will not consider states to have failed to enforce GFE requirements if they take these approaches from Jan. 1, 2022, through Dec. 31, 2022.
If you or a co-facility or co-provider anticipates or is notified about any changes to the scope of a previously-furnished GFE at the time of scheduling, you must provide the uninsured or self-pay individual with a new GFE no later than one business day before the services or items are scheduled to be furnished.
If any changes in expected facilities or providers in a GFE occur less than one business day before a service or item is scheduled to be furnished, the replacement facility or provider must accept the GFE provided by the former facility and provider.
If the patient is uninsured or self-pay, you must provide them with a new GFE for the scheduled service or item according to the standard time frames in the "Time Frames for Providing Good Faith Estimates to Individuals" section of this guide.
You must prominently display clear, comprehensive, and easy-to-find information about the availability of GFEs for uninsured or self-pay individuals in your office, on your site, and wherever scheduling and questions about the cost of services and items happen. The GFE information on your site must be easily searchable from a public search engine like Google or Bing. Feel free to use these model notices as references.
You must also provide information about GFEs for uninsured or self-pay individuals when scheduling a service or item or when asked questions about the cost of services or items. You should consider any inquiry or discussion about the potential cost of services or items as a GFE request.
Additionally, you must make information about GFE availability for uninsured or self-pay individuals available in:
Co-facilities and co-providers must submit GFE information upon your request. They must provide the GFE information no later than one business day after receiving your request.
Additionally, co-facilities and co-providers must provide new GFE to you if they anticipate any changes to the scope of the GFE information previously submitted. This includes anticipated changes to the expected services, charges, recurrences, items, providers, duration, or facilities.
If any changes to the co-facilities and co-providers listed in the GFE happen less than one business day before the service or item is scheduled to be furnished, the replacement co-facility or provider must accept the GFE for the relevant services and items included in the GFE provided by the replaced facility or provider as its GFE of expected changes.
If a self-pay or uninsured individual separately requests or schedules a GFE from a facility or provider that would otherwise be a co-facility or co-provider, that facility or provider must meet all requirements for GFE-issuing convening facilities and providers.
A GFE issued to a self-pay or uninsured individual must include:
You can use charts like this to list out expected services or items for uninsured or self-pay individuals:
Include the total expected charges and additional notes at the bottom.
GFE information submitted to you by co-providers and co-facilities for inclusion in GFEs must include:
Starting Jan. 1, 2022, a PDDR process will be available for self-pay or uninsured patients who receive a bill for a service or item that costs $400 or more than the expected charges on their GFEs.
Under the PPDR process, the self-pay or uninsured individual may request a determination from a Selected Dispute Resolution (SDR) entity for the amount they have to pay. This can give the individual vital consumer protections from charges that are much higher than the expected GFE estimates.
The PPDR process can apply to any service or item furnished by a convening facility, provider, co-facility, or co-provider to a self-pay or uninsured individual where the total billed charges are $400 or more than the GFE amounts.
If a co-facility or a co-provider that provided a GFE service or item estimate is replaced by another co-facility or co-provider less than one business day before that service or item is scheduled to be furnished, that item or service is eligible for dispute resolution if the billed charge is $400 or more than the total expected GFE charges.
If the replacement facility or provider provides the self-pay or uninsured individual with a new GFE on time, the item or service is only eligible for dispute resolution if the total billed charge for the replacement co-facility or co-provider is $400 or more than the total expected charges in the replacement co-facility or co-provider's GFE.
GFE and PPDR requirements work together to establish key consumer protections for self-pay or uninsured individuals who receive medical bills that are $400 or more than their GFEs. PPDR requirements apply to all facilities and providers subject to GFE requirements.
Yes. Providers and facilities can settle their payment disputes through the PPDR. HHS recognizes both parties have a right to resolve disputes through the PPDR process.
After the PPDR process has started but before the date of the SDR's determination, both parties can settle the payment amount through:
A GFE must be provided within the time frames described above in written form, either electronically or on paper, depending on the self-pay or uninsured patient's preferences. Electronically-provided GFEs must be provided in a manner that the self-pay or uninsured individual can both print and save. Meanwhile, GFEs provided to self-pay or uninsured patients through paper mail must be postmarked by the timelines in the "Time Frames for Providing Good Faith Estimates to Individuals" section.
If an uninsured or self-pay individual requests a GFE in a form other than electronic or paper, such as orally or by phone, you may orally inform the individual of the information in the GFE using the requested method. However, you must also issue the GFE to the uninsured or self-pay individual in written form to meet the requirements of this section.
Additional GFE requirements and gotchas include:
A GFE issued to a self-pay or uninsured individual is considered part of the patient's medical record. Accordingly, you must maintain it like a patient's medical record. As a convening facility or provider, you must also provide a copy of any previously issued GFE furnished within the last six years to a self-pay or uninsured individual upon the individual's request.
Note that you will not fail to comply with federal GFE requirements solely because you have made an omission or error in a GFE, provided that you correct the information as soon as possible. If services and items are furnished before a GFE error is addressed, you may be subject to PPDR if the actual billed charges are "substantially in excess" of the amounts in the GFE. HHS regulations define "substantially in excess" as $400 or more above the GFE amounts.
Similarly, you are not failing to comply with federal GFE requirements if you rely on information from another provider or facility to obtain information from another individual or entity unless you know or reasonably should have known that the information is inaccurate or incomplete. If you discover the information is incomplete or inaccurate, you must provide corrected data to the uninsured or self-pay individual as soon as possible. If the services or items are furnished before you can address the GFE error and the actual billed charges are $400 or more than the GFE amounts, you may be subject to PPDR.
As you can see, the No Surprises Act establishes strict guidelines for creating and sending GFEs.
Specifically, you must:
1. Determine whether someone needs a GFE.
2. If certain requirements are met, issue a single estimate for recurring items or services.
3. Provide GFEs according to No Surprises Act time frames.
4. Provide the self-paying or uninsured individual with a new GFE no later than a business day if you anticipate or are notified about any changes to previous GFEs.
5. Display prominent notices about the availability of GFEs for uninsured and self-paying individuals.
6. Get co-providers and co-facilities to submit GFE information within one business day after your request.
7. Include the right content in your GFEs.
8. Participate in the PPDR process as needed.
9. Provide GFEs in paper or electronic form.
10. Consider GFEs part of patients' medical records.
11. Correct omissions and errors as soon as possible.
If you don't follow the No Surprises Act requirements, you may be subject to civil monetary penalties of up to $10,000.
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