The Centers for Medicare and Medicaid Services (CMS) announced in guidance that it will continue to delay enforcing the convening/co-provider good faith estimate (GFE) requirement of the No Surprises Act (NSA) as well as the NSA’s Advanced Explanation of Benefits (AEOB) requirement. In the NSA implementing regulations, CMS announced it would not enforce these provisions in 2022 because there were still many operational aspects of those requirements that need to be resolved.
CMS still has not issued regulations regarding implementation of those requirements and instead issued a Request for Information (RFI) to solicit public input. The absence of new regulations explaining how CMS will implement these provisions, and comments from CMS in the RFI, suggested CMS would not begin enforcing these provisions in 2023. This new guidance makes the delay official. CMS is extending its enforcement delay indefinitely pending the issuance of implementing regulations.
The enforcement delay does not impact the portion of the GFE which took effect on Jan. 1, 2022. Beginning this year, essentially all health care providers and facilities are required to furnish uninsured or self-pay patients with a GFE either upon request or upon scheduling care. This GFE only needs to include the primary item or service for which the patient is requesting or scheduling care. Get more details on NSA requirements for allergists in the College’s Risk and Compliance Toolkit.
The two provisions subject to this enforcement delay are:
- Convening/co-provider GFEs. The NSA statute requires GFEs to include care reasonably expected to be furnished in connection to the primary item or service, regardless of whether the other co-providers or co-facilities are part of the same practice or health system as the provider who furnishes the primary item or service.
- AEOBs. The AEOB provision requires convening providers to send the completed GFE to a patient’s health plan so the health plan can then furnish the patient with an AEOB that lists the GFE price and the in-network price side-by-side for the patient to compare.
CMS decided to delay enforcement of the GFE connected care and the AEOB requirements because it acknowledges how administratively burdensome it will be for providers and health plans to facilitate the communications necessary to satisfy these provisions. The delay gives CMS more time to develop the technical standards necessary to facilitate these two provisions.
Separate from that guidance, CMS also published new FAQs about GFE implementation. The FAQs explain how to include items or services that will not be billed to the patient in GFEs. The guidance also provides clarifications on how sliding fee schedules can comply with the GFE requirement.
The FAQs provide other clarifications about the Patient-Provider Dispute Resolution (PPDR) Process that patients can use to arbitrate medical bills for items or services that exceed their GFE price by at least $400. HHS encourages providers to include an email address and phone number for someone that has the authority to represent the provider or facility in a billing dispute (for example, a medical billing specialist, general counsel, or compliance officer) in the GFE.
The Advocacy Council will continue to update you as the provisions of the NSA change. The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.