‘Good faith estimate’ requirement takes effect: What you need to know

Clarification of a new billing disclosure requirement puts all health care providers on notice, drawing swift rebuke from physicians’ groups and the AOA alike as the latter prepares additional guidance for optometry practices.

Beginning Jan. 1, 2022, all providers and facility types are required to provide uninsured (or self-pay) patients with a “good faith estimate” (GFE) of charges for items and services reasonably expected to be delivered before services are scheduled or upon the patient’s request. Such GFEs, outlined in federal rules implementing the No Surprises Act, must provide self-pay or cash pricing and must reflect the expected charges, including any expected discounts or other relevant adjustments, that may apply to an individual’s actual billed charges.

The No Surprises Act, a federal law passed with the bipartisan Consolidated Appropriations Act, 2021, outlines protections against “surprise” medical bills surfacing when patients inadvertently or unknowingly receive care from out-of-network providers. Often addressing emergency care situations or hospital expenses, the No Surprises Act was heralded as providing patients “more choice, better service and lower prices” when it passed in late 2020. Yet, the recent rulemaking process stoked concerns that such new requirements add little overall value and instead heap regulatory burden on an already stressed health care system.

On Sept. 30, the Department of Health and Human Services (HHS) released interim rulemaking that drew an immediate response from physicians’ groups, including the AOA, not only for its method of resolving payment disputes between plans and providers but also its lack of clarity on key points, such as the GFE. Additionally, over 150 members of Congress echoed many of the same concerns in a November letter to the secretaries of HHS, Labor and Treasury, urging the administration to align regulations with the law as written.

“We appreciate the complex nature of the patient protections that must be established and look forward to a final rule that accurately reflects Congress’s multi-year bipartisan and bicameral work to pass this landmark legislation,” the legislators’ letter reads.

Given how so much of the No Surprises Act pertains only to hospitals and surgical centers, the AOA and other associations, such as the American Medical Association, requested the HHS to clarify what types of health care providers would be required to provide GFEs. In response, the HHS clarified on Dec. 27 that “generally, all providers and facilities that schedule items of services for an uninsured (or self-pay) individual or receive a request for a GFE from an uninsured (or self-pay) individual must provide such individual with a GFE. No specific specialties, facility types or sites of service are exempt from this requirement.”

In a Jan. 3 letter to HHS Secretary Xavier Becerra, the AOA noted serious concerns about the HHS’ response and applicability of the rule to doctors of optometry. The letter emphasized that the lack of initial clarity on GFE applicability in the interim rule, as well as the added stress of such a regulatory burden on doctors of optometry when staffing issues and COVID-19 remain prominent concerns, should prompt the HHS to postpone implementation of this rule at least until additional feedback is available from physician practices. For its part, the HHS indicated it would use its discretion over GFE enforcement this year.

“While we fully appreciate and support the HHS decision to exercise its enforcement discretion related to this provision until Dec. 31, 2022, we strongly urge the agency to reconsider the requirements and to delay any implementation of these new requirements to allow for additional time to work with physician practices to develop an approach that can meet the goals of the NSA and better consider the practical impact of these rules on physician practices,” the AOA notes.

AOA offers resources, guidance on GFE compliance

Although the HHS has indicated some enforcement discretion in 2022, the AOA emphasizes that doctors of optometry must familiarize themselves with the GFE requirements. In addition to an AOA frequently asked questions document, the Centers for Medicare & Medicaid Services (CMS) offers guidance, including a detailed frequently asked questions document and a template GFE form.

For optometry-specific guidance and further information about GFEs and the No Surprises Act, an upcoming #AskAOA webinar will be led by Jeff Michaels, O.D. Doctors will be able to use information shared on the webinar to make immediate changes to comply with the GFE requirement. Dr. Michaels also will provide a brief update on the Provider Relief Fund Reporting that is required in Q1 2022.

“These new rules will require a little bit of change by our members, but the webinar will bring them quickly up to speed with how to implement these changes,” Dr. Michaels says. “We are constantly working to keep our members updated with the latest regulatory information, and that is why we’re providing this webinar: every doctor of optometry will need to comply with this GFE requirement.”

WHAT: #AskAOA: No Surprises Act Update
WHEN: 9 p.m. ET, Monday, Jan. 24

If you would like to submit a question to be addressed during the webinar, please email askaoa@aoa.org. Find more information about the No Surprises Act and the #AskAOA webinar.