Good Faith Estimate
Good Faith Estimate (GFE) has been a hot topic of discussion lately. We wanted to provide additional information to educate our members on this topic.
GFE is part of the No Surprises Law and is enforced by the Department of Health and Human Services (HHS). This estimate is ONLY REQUIRED for cash pay patients. If you have Out-of-Network (OON) patients who will be submitting claims to their insurance after paying you cash, they are not entitled to a GFE.
A GFE must be given verbally any time a patient (or potential patient) requests one. If the patient schedules three days in advance, the GFE must be provided in writing within one day of scheduling their appointment. The GFE delivery method is up to the patient, and they may choose electronic, which must be given in a HIPAA compliant manner or provided a hard copy of the estimation of services. If the GFE is sent electronically, the patient must have access to a hard copy as well. If the patient does not schedule, the in writing estimate is not required. If a potential patient calls for an estimate, schedules an appointment, cancels, and then calls back ten days later to schedule, a new estimate must be provided. If the patient schedules more than ten days ahead, you have three days to provide the GFE to the patient. If a potential patient is scheduling two days or less in advance, there is no guidance provided. To be safe, it is recommended to provide a GFE to the patient on the first visit with your other disclosures.
Durable Medical Equipment (DME) is to be included in your GFE estimation. Based on an initial call with the front desk, it can be impossible to determine if the potential patient will need DME. However, you can revise your GFE after evaluating the patient. If determined on the initial phone call you expect to provide DME, you should add this to your estimate. If you find there is a need for DME, you should also add a disclaimer to your GFE that there may be items/services that must be scheduled separately and are not included in the GFE.
Clinics must display in their practice and on their website that patients are entitled to a Good Faith Estimate.
Your GFE is good for 12 months. You can provide one GFE for recurring services if you list the frequency, date range of services, and/or recurring items or services. Estimated total charges can be a range dependent on the number of visits potentially needed.
What must be in the GFE?
- The patient’s name and DOB.
- Any applicable diagnosis codes.
- A description of the primary item/service.
- The date the primary item/service is scheduled.
- Itemized list of items or services grouped by provider or facility.
- Expected service (CPT) codes with expected charges.
- Name, NPI, and TIN of each provider or facility represented.
- The address of the facility where services will be provided.
You should have a disclaimer that the GFE is only an estimate, and actual charges may differ. Your disclaimer should also include that the GFE is not a contract, and it should inform the patient of their right to initiate a patient-provider dispute resolution process if the actual charges are $400.00 or more over the GFE. Provide information on how to obtain information to initiate the dispute, and that initiating a dispute will not adversely affect the patient’s quality of care.
It would be ideal to provide an updated GFE after the first visit or any time during treatment if the patient’s diagnosis, severity, or treatment plan is different than anticipated on the initial phone call. This will protect you from later disputes. Remind your patient that the GFE is an estimate.
There is no requirement to go back to the beginning of the year and give all current cash pay patients a GFE, but ensure you are providing this to your patients moving forward.
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