Federal Rule to Prevent Surprise Health Care Billing

See the “No Surprises Act Regulations 2022″ page on Socialworkers.org

Alert: Information in this blog post was updated on January 5, 2022

NASW will continue to monitor policy developments pertaining to surprise billing and update members as new information is made available. See January 5, 2022 update.

Application to Clinical Social Work Services

December 21, 2021

Under a new federal rule to protect consumers from surprise health care bills, clinical social workers  and other health care provider types must, effective January 1, 2022, provide a good faith estimate of expected charges.

Under a new federal rule to protect consumers from surprise health care bills, clinical social workers and other health care provider types must, effective January 1, 2022, provide a good faith estimate of expected charges.

Under a new federal rule to protect consumers from surprise health care bills, clinical social workers (CSW) and other health care provider types must, effective January 1, 2022, provide a good faith estimate (GFE) of expected charges that may be billed for items and services to individuals who are uninsured (e.g., not enrolled in any health plan or coverage) or who are self-pay (e.g., not seeking to file a claim with their plan or coverage). The GFE must be provided both orally and in writing, upon request or at the time of scheduling health care items and services, and within specific timeframes.

The rule applies to both current and future patients who are uninsured or self-pay. However, GFEs do not need to be provided to patients who are enrolled in federal health insurance plans (e.g., Medicare, Medicaid, TRICARE, Indian Health Service or the Veterans Affairs health system).

Providing a GFE to patients is not new to CSWs who, as part of best clinical practice, routinely discuss services and fees before or during the initial interview with new patients.

Federal Rule Background and Definitions

On October 7, 2021, an interim final rule was issued by the U.S. Department of Health and Human Services and several other federal agencies, the Requirements Related to Surprise Billing; Part II.

Below are definitions of a several key terms in the rule as they apply to CSWs:

“Convening provider” or facility: That who receives the initial request for a good faith estimate and who is responsible for scheduling the primary item/service in question.

“Expected charge” for an item or service:

  • the cash pay rate or rate established by a provider for an uninsured (or self-pay) patient, reflecting any discounts for such individuals; or
  • the amount the provider would expect to charge if the provider intended to bill a health care plan directly for such item or service.

“Items and services”:  All encounters, procedures, medical tests provided or assessed in connection with the provision of health care. Services related to mental health substance use disorders are specifically included.

“Provider”: Any health care provider who is acting within the scope of the provider’s license or certification under applicable state law. CSWs meet that definition.

Compliance Steps

To comply with the new federal rule, CSWs should take the following steps:

  • Ask patients if they have any health insurance coverage and ascertain if they are uninsured or self-pay. If a patient is insured, make a copy of the insurance card for your files and ask the patient if they plan to submit a claim for the services they will receive.
  • Inform all uninsured and self-pay patients of their right to a GFE. Written notice must be provided in clear language that the individual can understand in an accessible format, prominently displayed in the office and on the provider/facility’s website and must be easily searchable from a public search engine. Written notices should account for any vision, hearing or language limitations, including individuals with limited English proficiency or other literacy needs. It may be provided on paper or electronically, depending on the individual’s preference. The written notice should also state that information will be orally provided when the service is scheduled or when the patient asks about costs, and available in accessible formats, in the language(s) spoken by the patient.
  • Provide all uninsured or self-pay patients with a GFE. This must include:
    • Patient name and date of birth.
    • a clear description of each item/service with diagnosis codes, expected service codes and expected charges associated with each listed item or service (and date of service if scheduled).
    • an itemized list of items/services reasonably expected to be furnished in conjunction with the primary item/service grouped by provider/facility along with the NPI/TIN and location of each.
    • provider’s name, National Provider Identification (NPI) number, and Tax Identification Number (TIN) and office (s) where the items or services are expected to be furnished.
    • a disclaimer that the GFE is only an estimate of items/services reasonably expected to be furnished at the time and final items, services or charges may differ. (For recurring services, see “GFEs for Recurring Services”, below).
    • a disclaimer that additional recommended items or services may be part of the course of care but are not reflected in the GFE along with a separate list of items/services that require separate scheduling and for which separate GFEs would need to be requested.
    • a disclaimer informing the patient of their right to initiate the patient-provider dispute resolution (PPDR) process if the actual billed charges are substantially greater than the estimated charges along with instructions of where to find more information and written assurance that initiating such process will not adversely affect the quality of services rendered. (See “Disputes”, below).
    • a disclaimer that the estimate is not a contract and does not require the individual to obtain the items or services from any of the providers or facilities identified.
  • Explain the GFE to the patient over the phone or in-person if the patient requests it, and follow-up with a paper or electronic GFE.
  • Document the GFE in the clinical record.

CSWs who are employed by group practices and other types of health care facilities should contact their compliance officers for guidance.

Timeframes

Information regarding scheduled items and services must be furnished within one (1) business day of scheduling an item or service to be provided in three (3) business days; and within three (3) business days of scheduling an item or service to be provided in at least 10 business days. A new GFE must be provided, within the specified timeframes if the patient reschedules the requested item or service. If any information provided in the estimate changes, a new GFE must be provided no later than 1 business day before the scheduled care. Also, if there is a change in the expected provider less than one business day before the scheduled care, the replacement provider must accept the original GFE as their expected charges.

GFEs for Recurring Services

If you expect to provide a recurring service to the uninsured or self-pay patient, you may submit a single GFE to that patient for those services, so long as the GFE includes, in a clear and understandable manner, the “expected scope of the recurring primary items or services (such as timeframes, frequency, and total number of recurring items or services)”.  The GFE can only include recurring services that are expected to be provided within the next 12 months. For additional recurrences beyond 12 months, the provider must provide a new GFE and communicate any changes between the initial and the new estimates.

For example, if you have a patient whom you expect will need continuing services throughout the year, the GFE could say: “I expect that my care of you will require continued weekly therapy sessions continuing through the end of the year, at $X per session for a total of 50 weeks, accounting for vacations and holidays for an estimated total of AMOUNT.”

If the future course of treatment is less certain, the GFE could say: “Depending on the progress we make this year, I expect that you will need 10–20 more sessions this year. At $X per session the estimated total cost would be AMOUNT.”

Templates and Resources

Find Centers for Medicare and Medicaid Services (CMS) resources, including templates that can be used to prepare good faith estimates and model language for informing patients of their rights to GFE.

Enforcement

GFEs are considered part of a patient’s medical record and must be maintained in the same manner. Accordingly, convening providers/facilities must be able to provide a copy of any estimates within the last six (6) years. Providers will not be considered non-compliant if they act in good faith and with reasonable due diligence and correct any inaccuracies as soon as practicable. HHS will exercise enforcement discretion in scenarios where convening providers and facilities are relying on the accuracy of expected charges for items or services for which they do not bill from co-providers or co-facilities, provided that they did not know or reasonably should have known, that the information was incomplete or inaccurate, and that they attempt to correct any inaccuracies as soon as possible. Providers/facilities who experience others’ failures to comply with these requirements may file a complaint for enforcement investigation.

Disputes

Although the information provided in the GFE is only an estimate, and the actual items, services, or charges may differ from what is included in it, uninsured or self-pay individuals may challenge a bill from a provider through a new patient-provider dispute resolution (PPDR) process if the billed charges substantially exceed the expected charges in the GFE. “Substantially exceeds” means an amount that is at least $400 more than the expected charges listed on the GFE.

Future Action

The federal government will also soon issue regulations requiring CSWs and other health providers to provide GFEs to commercial or government insurers when the patient has insurance and plans to use it.

NASW will continue to monitor policy developments pertaining to surprise billing and update members as new information is made available.


Disclaimer:  Legal and regulatory issues are complex and highly fact-specific and state-specific. They require legal expertise that cannot be provided in this article. The information in this alert does not constitute and should not be relied upon as legal advice and should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions.