Health & Wellness

Health Estimates and No Surprises Act

Health Estimates are statistical or mathematical models that make comparisons and provide an overview of global health indicators. They are based on a range of diverse data sources and analysis methods.

To help consumers navigate the complexity of medical costs and insurance, Cone Health has made it easy to get an estimate. To use the tool, simply enter a procedure name or Current Procedural Terminology (CPT) code.

What is a Good Faith Estimate (GFE)?

A Good Faith Estimate (GFE) was a document that mortgage lenders were required to send to borrowers within three days of receiving their application. It detailed the fees associated with a loan and allowed borrowers to compare options easily.

Since 2015, the GFE has been replaced with a Loan Estimate Form, which is easier to read and breaks down the costs of a loan. If you are thinking about purchasing a home, be sure to check out Rocket Mortgage(r), a quick and easy way to get a Loan Estimate.

Currently, providers and facilities are only federally required to offer a GFE to self-pay patients when they ask about costs or schedule services. But it’s important to let self-pay patients know that they have the right to a GFE and that if their actual charges are more than $400, they can start what’s called the selected dispute resolution process. Make sure to post this information on your website and in the office.

How can I get a GFE?

Lenders must give borrowers a GFE within three days of receiving their mortgage application. Having a GFE in hand will help borrowers compare loan offers from different lenders, helping them avoid surprises later on in the process.

Uninsured patients and self-pay insured patients must be provided a GFE by the convening provider or facility. GFEs should include primary services and items as well as those expected to be incurred by the patient at other facilities or providers.

For insured patients, a GFE is sent to the individual’s health plan and it is the health plan’s responsibility to incorporate it into an “advanced explanation of benefits.” The No Surprises Act provides additional requirements regarding when a GFE should be updated. For example, a new GFE should be provided if there is a change in the expected charges, items, services, frequency, recurrences, duration or providers. The GFE rules do not apply to those enrolled in federal health insurance programs such as Medicare, Medicaid, Tricare or CHIP.

What are my rights to a GFE?

Under the No Surprises Act, uninsured and self-pay individuals have a right to GFEs for scheduled services or items. This includes hospitals, doctors, air ambulance services, and even ancillary providers like cosmetic plastic surgeons, chiropractors, or physical, occupational, or speech therapists. GFE requirements do not apply to patients enrolled in Medicare, Medicaid, Tricare, or Indian Health Service.

Providers should make sure information about the availability of GFEs is prominently displayed both online and in-office. They should also ensure their staff is trained to explain the availability of a GFE when interacting with patients.

If a patient receives a bill for a service or item that exceeds the expected charges on their GFE by $400 or more, they have the right to participate in a patient-provider dispute resolution process (PPDR). This process is administered through HHS and does not interrupt the delivery of care. Detailed information about the PPDR process can be found on this Federal Site.

What are my responsibilities to get a GFE?

The No Surprises Act requires providers and facilities to notify uninsured patients of expected charges for scheduled items and services. This can include consultations, lab work, drugs, equipment and more. To be as accurate as possible, GFEs should detail charges associated with a comprehensive course of treatment. This may require collaborating with co-providers and co-facilities to ensure each component is included in a single estimate.

It’s important that organizations establish clear and repeatable procedures, preferably codified in formal policy, around generating, sending, and monitoring GFEs. They should also consider implementing tools to assist with scheduling and establishing internal controls that adapt to workflow changes and regulation updates. Finally, they should make training a priority to help mitigate variation and compliance risk. GFE requirements apply to physicians, air ambulance services, hospitals, outpatient clinics and imaging centers, but they also extend to ancillary providers like dentists, cosmetic plastic surgeons, chiropractors, and physical or occupational therapists. It’s also important that providers and facilities know the insurance status of a patient at the time of scheduling or request, and ask if they lose coverage before their appointment.

Related Posts

1 of 7