Basic steps for starting your good faith estimate compliance

American Psychological Association. (2022, February 23). Basic steps for starting your good faith estimate compliance. https://www.apaservices.org/practice/legal/managed/good-faith-estimate-compliance

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Here are some basic steps you need to take to start complying with the No Surprises Act good faith estimate (GFE) requirement for patients who are uninsured or who don’t intend to use their insurance:

1. Review the guidance from APA in New billing disclosure requirements take effect in 2022 and Understanding the No Surprises Act: How to provide estimates for your services. For detailed answers to frequently asked questions regarding compliance with the No Surprises Act and how to generate good faith estimates, please visit the FAQs on the No Surprises Act and good faith estimates page.

2. Provide patients with and prominently display a “GFE notice” about a patient’s right to a GFE. You can use HHS’ model notice form (PDF, 129KB) . Post this notice on your website and, if you are seeing patients in person, in your office. You (or your scheduling staff) should also notify uninsured/self-pay patients (identified in Step 4) orally about their right to a GFE when making an appointment or when a patient asks about costs.

3. Create a GFE template for your practice. Many psychologists in independent practice can work with this simple one-page GFE form (DOCX, 26KB) . If you are coordinating services from multiple providers, you may need to work from the more complex template provided by CMS sample good faith estimate template (PDF, 163KB) . (See FAQs on the No Surprises Act and good faith estimates for guidance on this scenario).

4. Determine if your patient should receive a GFE. Ask each patient:

A) if they have any kind of health insurance coverage, and

B) if they have private or other insurance (other than federal health insurance programs like Medicare, Medicaid, Tricare, or CHIP), do they intend to use that insurance for your services.

If they answer yes to both questions, you do not need to give the patient a GFE at this time. (Later in 2022 or in 2023, when HHS develops regulations for patients who intend to use their insurance, APA will provide guidance for sending GFE information to that insurer.)

If the patient is in a federal health insurance program like Medicare or Medicaid, they don’t get a GFE because those programs have their own surprise billing protections for patients. Coverage through Tricare and CHIP are not explicitly mentioned, but APA expects they will be included in this exemption.

Federal Employee Health Benefits program members do get a GFE if they don’t intend to use that insurance.

Regarding question B, CMS supported APA’s interpretation that who submits a claim to the patient’s insurance (patient or psychologist) is not critical. Nor does it matter whether you are in or out of network with the patient. What is important is that the patient intends to use their insurance to cover your services.

The next steps apply only to those patients who answered “no” to one of the questions in step 4, placing them in the uninsured/self-insured category.

5. Give your patients an initial GFE.

When scheduling appointments:

For appointments scheduled three or more business days before the appointment date, provide the GFE within one business day after scheduling.
For appointments scheduled 10 or more business days before the appointment date, provide the GFE within three business days after scheduling.

For example, if on February 1 you schedule a session for February 7, give the GFE by February 2. If on February 1, you schedule a session for March 1, give the GFE by February 4.

The regulations do not address when to send the GFE if the appointment is scheduled less than three days out. If you are in that situation, we recommend that you send the patient a GFE as soon as practicable. Particularly with urgent situations, if you don’t have time to prepare a GFE before an appointment, you should orally convey an estimate at the start of the appointment (after handling any urgent issues) and follow up with a written GFE promptly after the appointment.

If the patient reschedules the appointment, you must provide an additional GFE, within the timeframes above. (Note: APA objects to this requirement and will advocate for its removal. APA sees no value in requiring a new GFE for rescheduling.)
When the patient requests a GFE (without scheduling the service) you should provide the GFE within three business days of the request.

6. Update your GFEs

You should provide updated GFEs to patients at least one business day before scheduled care under the following circumstances, listed in order of priority.

There are changes to service that significantly affect the cost of care. It is most critical to make sure that your actual billing does not exceed the current GFE by more than $400, however any changes in billing should trigger an updated GFE.
You continue to treat a patient beyond the time frame of the initial GFE.
Technically you are required to issue an updated GFE if you anticipate any changes to the “scope” of the GFE, such as anticipated changes to the “expected charges, items, services, frequency, recurrences, duration, providers, or facilities.” It is not clear exactly what changes to the “scope” means. It is also unclear what the negative consequences would be of not updating a GFE that is still in effect for minor changes that do not affect the patient’s costs. APA continues to argue to CMS that it is unduly burdensome to require psychologists to update GFEs for changes in GFE information that do not affect expected costs.