In 2020, Congress passed the No Surprises Act (NSA) in an attempt to protect patients from surprise billing. Some sections of the NSA became effective January 1, 2022, while other sections are on hold until regulations are released. See this post for a general NSA overview.

This weekly series provides answers to frequently asked questions regarding the NSA. The first FAQ installment answered general questions and focused on the requirement to notify patients of their NSA protections.

The second installment focuses on the applicability of good faith estimates (GSE) and this installment will cover GSE timing and logistics. 

Health care providers who would like to submit a question for inclusion in a future FAQ installment should email susan.freed@dentons.com

No Surprises Act and Good Faith Estimates- Timing & Logistics

When must the GFE be provided?

Convening providers (the provider who is scheduling the patient) must provide self-pay and uninsured patients with a GFE within one (1) business day after the date of scheduling. If the item/service is scheduled between three and nine business days in advance, then the GFE must be provided within three (3) business days after the date the service was scheduled. If a self-pay or an uninsured patient requests a GFE, the GFE must be provided within three business days of the date of request.

If multiple providers are involved in the service, who is considered the “convening” provider responsible for coordinating with co-providers and providing the GFE?

The convening provider is the provider who is responsible for scheduling the primary item or service or receiving the request from the patient for the GFE. The “primary item or service” is defined as the item or service that is the initial reason for the visit.

What if multiple providers are involved in scheduling the service with the patient, who is considered the “convening provider”?

As of the publication of this article, the regulations and guidance do not address this issue. If there is not one provider primarily communicating and scheduling the service with the patient, then we recommend the providers involved in scheduling the service to identify one provider to be the convening provider to ensure the parties are clear on who is serving in this capacity. This will be especially important starting in 2023 when the GFE must include all co-providers’ charges.

A new patient is scheduling a clinic visit for a complaint of frequent headaches. How do I prepare a GFE when I am unsure of what specific services will be provided at this visit (i.e, labs, imaging) since I have yet to assess the patient?

The regulations require the GFE to include all items/services reasonably expected to be provided in conjunction with the primary item or service during the period of care. In this case, the primary item or service is the clinic visit and the period of care is the date of the visit. If a provider requires all new patients complaining of headaches to undergo specific diagnostic tests, such as labs or imaging, on the day of the visit in connection with the provider’s evaluation of the patient, then such tests would be expected to be included in the GFE.

However, if the provider would vary their testing based on the results of a physical exam conducted at the clinic visit and does not have a reasonable expectation at the time of scheduling of what tests they may order to be done on the day of the clinic visit, no additional items/services would need to be included in the GFE.

If any tests ordered by the provider would be separately scheduled and not provided on the date of the visit, then these tests would be subject to separate GFE requirements if scheduled three or more business days in advance or if the patient requests one.

A patient will be undergoing a knee replacement which will require the following services in addition to the surgery: a pre-op visit in advance of surgery, imaging, lab tests, a post-op visit, and a period of therapy. Would these services be included in separate GFEs or in one GFE?

All services provided in connection with the surgery from admission through discharge would be included in the knee replacement surgery GFE (such as professional fees, anesthesia, prescription drugs, and DME). Any services separately scheduled by the patient, such as pre-op and post-op appointments and therapy visits would be in separate GFEs. Note, however, that the GFE content requirements do require the convening provider to include a list of items or services provided before or after the primary item or service and which require separate scheduling so these services would be listed in the GFE but without further information such as charges, list of providers, etc.

A physical therapy patient is undergoing a course of therapy expected to be three days a week for six weeks. Do I need to provide separate GFEs for each therapy visit?

No, the regulations allow providers who provide patients with “recurring” services to provide one GFE covering all recurring services within a 12-month period as long as you explain the timing and frequency within the GFE and the costs do not change. If recurring services last more than 12 months, a new GFE would need to be provided every 12 months.

Can co-providers simply provide a separate GFE instead of including their charges in the convening provider’s GFE?

Starting January 1, 2023, the GFE must include all of the providers’ charges, including the co-providers’ and convening provider’s charges. Until January 1, 2023, the regulators are using their enforcement discretion and have indicated convening providers are not required to include co-provider charges in their GFE. Therefore, during 2022 providing separate GFEs is allowable. Starting January 1, 2023, convening providers and co-providers must have a process in place to provide one GFE to self-pay patients.

Related Resources:

• No Surprises Act: Volume 1 - Scope, Effective Dates, and Patient Notice
• No Surprises Act: Volume 2 - Good Faith Estimates Applicability
• No Surprises Act Limits Out-of-Network Charges