Update 4/6/2022: CMS has issued a new FAQ with minor clarifications about the rules:
For example, FAQ includes discussion about situations where diagnosis codes are not required to be included with an estimate:
“[I]n situations in which a provider or facility has not
determined a diagnosis, such as for initial screening visits or evaluation and management visits;
or if there is not a relevant diagnosis code for an item or service, such as for certain dental
screenings or procedures, providers and facilities are not required to include diagnosis codes on a
Also included in the FAQ, are clarifications about Good Faith Estimates for future visits and periodic care.
Text of original AAPS alert 12/29/2021:
Late last year AAPS warned the nation about the bad surprises in the so-called No Surprises Act, buried in the longest bill ever passed by Congress. We also led an effort to encourage President Trump to veto the 5,593 page bill.
Unfortunately, now a year later, the Biden Administration is pushing forward with implementing the provisions of the law.
While the purported goal of the bill—protecting patients from unexpected medical bills—may sound attractive, piling even more red tape on physicians is the wrong way to fix problems created by past government medical policy failures.
AAPS continues the hard work of rolling back improper government intrusion into medicine like this, but for the moment, there are new rules stemming from this legislation, the Biden Administration has announced, that take effect January 1, 2022.
One of the new Biden Administration rules that has implications for physicians treating self-pay patients is outlined at 45 CFR 149.610, “Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals.”
These regulations include “requirements of providers and facilities” to:
Provide a good faith estimate [of expected charges] (as specified in paragraph (c)(1) of this section) to uninsured (or self-pay) individuals within the following timeframes:
(A) When a primary item or service is scheduled at least 3 business days before the date the item or service is scheduled to be furnished: Not later than 1 business day after the date of scheduling;
(B) When a primary item or service is scheduled at least 10 business days before such item or service is scheduled to be furnished: Not later than 3 business days after the date of scheduling; or
(C) When a good faith estimate is requested by an uninsured (or self-pay) individual: Not later than 3 business days after the date of the request.
The rule also requires: “Informing all uninsured (or self-pay) individuals of the availability of a good faith estimate of expected charges upon scheduling an item or service or upon request.”
Note that beginning January 1, 2022, there are additional rules, disclosure, and consent requirements, related to care from out-of-network physicians providing care at certain in-network facilities: https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf
AAPS is looking for opportunities to challenge these rules. If you are contacted by CMS about these rules or hear about a related enforcement action by CMS, please reach out to us ASAP.
- An FAQ document provided by CMS about the “Good Faith Estimate” rule can be accessed at:
- Additional Fact Sheets, Guidance, and Technical Resources for compliance: https://www.cms.gov/nosurprises/Policies-and-Resources/Overview-of-rules-fact-sheets
- CMS Model Disclosure Notice
- CMS Model Good-Faith Estimate Template
- Text and Discussion of Interim Rules as published in Federal Register – https://www.federalregister.gov/d/2021-21441/p-264
- PYA analysis & implementation guide – https://www.pyapc.com/insights/no-surprises-act-implementation-guide-2-good-faith-estimate-requirements/
- AAFP concerns about implications for Direct Primary Care (DPC) practices – https://www.aafp.org/dam/AAFP/documents/advocacy/payment/dpc/LT-CMS-SurpriseBillingPart2-120321.pdf