Understanding the No Surprises Act: How to provide estimates for your services

Following the implementation of the No Surprises Act on January 1, 2022, many psychologists have expressed confusion and concern regarding the requirement to provide uninsured and self-pay patients with a good faith estimate (GFE) of the predicted cost of services.

The GFE requirement under the No Surprises Act aims to give patients and consumers a clear sense of what upcoming health care services will cost.

We’ve heard members’ concerns and have provided the following compliance resources:

• Clarified and updated guidance on compliance and enforcement
• FAQs to address some common questions
• An updated list of basic steps you can take to start complying now, with additional details clarifying that psychologists do not have to provide a GFE to patients who have but do not intend to use federal health insurance (such as Medicare and Medicaid).
• Resources to help with your compliance: A revised simple GFE form (DOCX, 26KB). This revised form will help explain to patients that they can only initiate the dispute resolution process if your billing submitted to them is $400 more than the most recent GFE. We also provide an Excel spreadsheet (XLSX, 13KB) for making sure that your billing does not substantially exceed your GFEs
• APA’s advocacy direction on this issue

Our big picture message is you should not panic or get upset if you can’t immediately figure out all the details of the new GFE requirements. Instead, make a good faith effort to comply—with the guidance and resources we are providing and will continue to provide.

Based on how APA has seen the Centers for Medicare and Medicaid Services (CMS) roll out similarly complex requirements for providers (e.g., HIPAA and Information Blocking/Open Notes), APA expects that CMS will delay hard enforcement until providers have had some time to figure out implementation, and APA expects CMS and other regulators to apply a softer, educational touch where providers have made a good faith effort to comply, even if they get some details wrong.

Until CMS develops further enforcement guidance, APA’s view is that the main risk to psychologists will be in cases where actual costs for services to a patient exceed the latest GFE by over $400, triggering the patient’s right to initiate dispute resolution. This can be avoided by tracking patient billing vs. your GFE. You can use the Excel spreadsheet for that. The FAQs page suggests GFE strategies for reducing that risk.

APA Practice and Advocacy have been evaluating our advocacy approach internally and with other major mental health groups. There are two main components. First, APA plans to address requirements currently in effect (for uninsured and self-insured patients) with CMS as well as aspects of the regulations that are unduly burdensome, don’t further the law’s objective of making health care costs clearer to patients, or compound the difficulties mental health providers face from the lack of oversight in compliance with federal parity law. Second, APA will seek a reconsideration of these regulations, and a full and fair opportunity to comment on future proposed regulations. APA will also obtain CMS guidance on GFE details that remain unclear, e.g., when should your GFE include estimates from other providers that are part of your treatment plan for the patient.

APA will engage in advocacy on various fronts, including but not limited to seeking a meeting with CMS, in anticipation of the next major regulatory action this year from the No Surprises Act: GFEs for insured patients who intend to use their insurance for the provider’s services. For those patients, the psychologist will likely send a GFE to the insurer, which will then figure out what portion it expects to pay and send patients an advance explanation of benefits. This process raises multiple concerns, such as how out-of-network psychologists will communicate to insurers, how insurers determine out-of-network reimbursement, whether insurers will attempt to use psychologists’ GFE’s to limit care, and whether insurers will use the dispute resolution process to suppress payment rates.