The No Surprises Act: Good Faith Estimates for Rehab Therapy.

The only constant in the world of outpatient rehab therapy is change. Especially with new legislation like the No Surprises Act that went into effect in 2022. If you offer cash-pay services, your clinic will need a Good Faith Estimate template at the ready.

Cash-based PT, OT, & SLP is designed for patients who aren’t insured or choose to self-pay. For many clinics, cash-pay services reduce some of the operational complexity because you don’t have to file with insurance. But the No Surprises Act adds another layer to the process. Here’s what you need to know:

What is the No Surprises Act?

Picture it: you’re having a medical emergency—a stroke, perhaps—and your only goal is to get to the nearest hospital. Your spouse calls an ambulance, which takes you to the ER. You undergo tons of tests, scans, and lab work to see what actually happened and get you on the road to recovery. You come out of the hospital the next day ready to move on with life!

All is well until weeks later when you get a bill for your ambulance. And then another bill from the ER. And another from radiology. And so on. You might notice that your hospital was in-network, but none of the doctors that treated you accept your insurance. Now, you’re saddled with a huge out-of-network tab despite having the protection of insurance.

Sound familiar? For future generations, it won’t. That’s because the No Surprises Act is designed to stop these scenarios for good.

Passed in 2020, the No Surprises Act protects patients from surprise medical bills, particularly in cases where they cannot choose their medical providers. In an emergency, you don’t usually have this luxury.

Navigating Good Faith Estimates.

For the most part, providers in emergency services and large facilities will be most affected by this new bill. But some of it also applies to PTs, OTs, & SLPs.

The No Surprises Act contains one mandate called the Good faith Estimates (GFEs), which applies to providers of all shapes and sizes. Good faith estimates are estimates offered in good faith to uninsured, underinsured, or cash-pay patients for services they expect to receive. This way, patients know what they are likely to pay for a service beforehand, which helps eliminate any surprise medical bills.

How to provide Good Faith Estimates.

You might wonder: are there any rules I need to follow when providing a good faith estimate? The simple answer is: yes!

The more thorough answer is this:

• The provider must verbally inform all uninsured or cash-pay patients that they will receive an estimate for services either upon scheduling an appointment or upon request.
• The Good Faith Estimate should be provided in the patient’s spoken language and written in easy-to-understand verbiage (no complicated jargon or structure).
• The Good Faith Estimate should factor in any financial assistance the patient may be eligible for, such as discounts, assistance programs, or sliding scales.
• The Good Faith Estimate should be provided either as a paper hardcopy or an electronic file. If delivered as a hardcopy, the estimate should be delivered in person or mailed to the patient. If delivered as an electronic file, the file should be savable and printable (e.g., a Word doc or PDF).
• All estimates are considered part of a patient’s medical record and, therefore, should be kept on file for a minimum of six years.
• The Good Faith Estimate will expire after one year and should be reissued if a patient seeks services after the one-year period ends.
• The actual charge of service should total no more than $400 more than the cost provided in the Good Faith Estimate; otherwise, the patient has the right to dispute the bill.

There are also specific timeframes a provider must follow when providing Good Faith Estimates to patients:

And if you need to update a Good Faith Estimate that you’ve already given to a patient, you must do so no more than one business day before the scheduled appointment.

What to include in a Good Faith Estimate.

Use a Good Faith Estimate template, like this one from CMS, or for Insight users we have GFE templates pre-loaded and ready to use just search our Letter Templates library. These templates are compliant and contain everything your patients need to know. But if you prefer to reinvent the wheel or customize your Good Faith Estimates for your clinic, you’ll want to include the following:

• The patient’s name
• The patient’s date of birth
• A description of the service that the patient is inquiring about or that the provider is recommending based on the patient’s needs
• The date of the scheduled service, if applicable
• An itemized list of services or items and their prices, grouped by provider or facility, that are expected to be furnished as part of the service
• The patient’s primary (and secondary, if applicable) diagnosis code
• The name and NPI of each provider named in the Good Faith Estimate
• The tax ID of each provider or facility named in the estimate
• The location where each provider will perform or furnish the service
• A list of expected items that will require additional scheduling
• The required disclaimers, including:
  • A statement that you will provide additional Good Faith Estimates to patients upon their request.
  • A statement that for any listed items that may require additional scheduling, you will submit additional estimates upon scheduling or at the patient’s request.
  • A statement on how to obtain additional Good Faith Estimates.
  • A statement that informs the patient that you (the provider) may recommend additional services or items not listed that will be scheduled separately and will, therefore, not be included in the Good Faith Estimate.
  • A statement to clarify that a Good Faith Estimate is, at its heart, an estimate and that actual charges may vary.
  • A statement informing patients that they have the right to dispute a medical bill if they are substantially more than the Good Faith Estimate indicates. In addition, you must include directions on how patients can begin the Patient-Provider Dispute Resolution Process.
  • A statement to clarify that Good Faith Estimates are not contracts and that patients have the right to refuse services or treatments from providers or facilities listed in the estimate.

With so many details to include, it’s best to start with the template and customize it to your clinic.

Looking for a good faith estimate example? Try this good faith estimate form free download from CMS.

What else to know about the No Surprises Act.

If you’re already providing this level of detail into billing charges for all of your patients—that’s great! The big thing right now for providers to understand is the consequences of not following the specifics of a Good Faith Estimate. Namely, your patients will have the right to dispute their bills if their charges are drastically more than what you initially estimate them to be. In addition, the U.S. Department of Health and Human Services may impose a fine of up to $10,000 per violation and/or a corrective action plan. This isn’t chump change, so providers need to do their due diligence to ensure compliance—for the patient’s benefit and your own.

When does the No Surprises Act take effect?

It’s a trick question: The No Surprises Act is already in effect. The bill passed in 2020 and took full effect on January 1, 2022. This means that, as of right now, you should be providing Good Faith Estimates to your cash-paying patients and patients who don’t have insurance.

Do I also need to provide a Good Faith Estimate to insured patients?

Currently, the No Surprises Act only requires you to provide Good Faith Estimates to patients who are paying cash or do not have insurance. However, many clinicians wonder if this will eventually apply to all patients, regardless of how they pay or their insurance status.

It’s tough to say right now, as no such ruling has been implemented. So far, the Department of Health and Human Services has not extended this ruling to patients who are enrolled in an insurance plan and will have a claim submitted on their behalf. So take a load off and don’t sweat it—at least for now.

If new rulings or legislation become available on this matter—or other issues that will impact your role as a PT, OT, or SLP—rest assured that Clinicient will keep you informed.