April 18, 2022
The Centers for Medicare and Medicaid Services (CMS) has released clarifying information about Part 2 of the No Surprise Act, Good Faith Estimates (GFEs). The frequently asked questions (FAQs) answer many of the questions that social workers asked when the No Surprise Act was implemented in January 2022. Part 2 focuses on services provided to the uninsured or self-pay patients who receive services provided by clinical social workers in independent practice. Social workers employed as salaried employees in hospitals, nursing homes, primary care, and other health settings should contact their administration for information regarding the use of GFEs in their setting.
In January 2022, NASW posted FAQs on GFEs for social workers. The document prompted additional questions from social workers some of which have now been clarified in the questions and answers below. This is a reminder that the GFEs are only completed for patients who are uninsured or self-pay.
If a diagnostic code has not been determined at the time of scheduling, what code should the social worker use on the GFE?
In the absence of a diagnostic code, the expected charge and service code for the service should be furnished. An example of a service code would be a Current Procedural Terminology (CPT) code.
Where is the GFE maintained?
The GFE is part of the patient’s medical record and must be maintained in the same manner as a patient’s medical record. See the HIPAA Privacy Rule, https://www.hhs.gov/hipaa/for-professionals/privacy/index.html
Are social workers required to provide a GFE for expected charges for future visits in the initial visit?
A social worker is not required to include a GFE for future services in an initial visit, however, following an initial visit, upon scheduling of additional services, a social worker must provide a new GFE that includes expected charges for the services expected to be furnished. In addition, a social worker may, but is not required to, issue a single GFE for recurring services.
Does a GFE need to be provided for each instance of a recurring service?
In circumstances where a social worker expects to furnish recurring services, such as psychotherapy services, a social worker may issue a GFE for those recurring services, rather than a GFE for each instance.
- A GFE issued for recurring services must be written in clear and simple language the expected scope of the recurring services, including time frames, frequency, and total number of recurring services. The scope of such GFE must not exceed 12 months. If additional recurrences of such recurring services are beyond 12 months, a new GFE must be provided if the social worker expects changes to the scope of a GFE such as expected changes in services, frequency, recurrences, and duration.
- A new GFE must also be issued to a patient no later than 1 business day before the services are scheduled to be furnished. The social worker must also communicate these changes to the patient upon delivery of a new GFE to help the patient understand what was changed between the initial GFE and the new GFE.
How does a social worker address situations where unforeseen items or services that were not scheduled in advance are furnished during a visit?
Charges for services that could not have been reasonably expected do not require a GFE. A GFE provided to a patient must include an itemized list of services that are reasonably expected to be furnished during the known period of care.
Is a social worker required to provide a GFE to patients upon scheduling same-day or walk-in services?
The requirement to provide a GFE to a patient is not triggered upon scheduling a service if the service is being scheduled less than 3 business days before the date the service is expected to be furnished.
In situations where the social worker does not provide a patient with a GFE when scheduling a service because they had health insurance, but upon arrival, it is discovered that the patient is now uninsured or self-pay. Should the social worker provide a GFE to the patient prior to providing service, even if it means rescheduling the service for a later date?
No. When a patient schedules an appointment, the social worker must inquire if the patient is uninsured or self-pay. If the patient is uninsured or self-pay at that time, the social worker must provide a GFE. In situations where a social worker has previously determined that a patient has insurance and becomes aware that a patient is uninsured or self-pay less than three business days in advance of the scheduled service, nothing in the GFE regulations requires that the social worker provide a GFE to the patient or reschedule an appointment to allow for the provision of a GFE.
For more information, read “FAQs About Consolidated Appropriations Act, 2021 Implementation”
Social workers should also review their state regulations for guidance regarding state-specific requirements for GFEs. NASW will keep its members informed as new information becomes available regarding the usage of GFEs.
Prepared by Mirean Coleman, MSW, LICSW, CT, Clinical Manager