No Surprises Act, Good Faith Estimates & Chiropractic

The No Surprises Act originally passed in late 2020. It was essentially, at the time, designed to protect uninsured and self-pay patients as well as patients who were seeing an out of network provider for an emergent procedure, such as an ER visit, from being billed an exorbitant or unexpected fee. As you know the benefit of seeing a participating provider in general is that there is an “agreed upon” reduction of the fee and possibly a reduced copayment amount and/or deductible that the participating provider has agreed to for the “privilege” of participating. Unfortunately when presenting to an ER or for a surgery most patients do not always have the time to request ONLY participating providers for their care. So, in essence, this bill was created to prevent this type of “surprise”, hence the name.

This particular aspect had no real bearing upon Chiropractors in general.   It then also included non-emergent care and again under the initial read, did not really pertain to Chiropractors. The claim now by some is that under this legislation there are new requirements that all state-licensed providers and facilities must follow when scheduling uninsured and “self-pay” patients. The most notable change is the requirement to provide a Good Faith Estimate in advance of scheduled services, or upon patient request, for all patients that self-pay for services (because they are uninsured or by choice). Some, including many state associations and practice management gurus, claim that this applies to chiropractors in private practice. 

They are basing this off of what the Centers for Medicare and Medicaid Services (CMS) state in regards to how they define who this applies to: "State Licensed Provider/Health Care Provider: Physician or other healthcare provider acting within the scope of practice of that license or certification under applicable state law". The problem is that CMS does not rule out any provider or facility because any provider or facility may be involved.

Regardless of what we state here and regardless of what anyone says, we urge you to consult your attorney and contact your state chiropractic licensing board to determine if this applies to you or not. We are providing this information in case your state is forcing you to comply or you fall into a grey area.

First, understand that there are two parts. Part I tells us which services are involved and where they are provided.  Healthcare Facility is defined as: a hospital, hospital outpatient, critical access hospital, ambulatory surgical center, rural health center, federally qualified health centers, labs and imaging centers.

This would seem on the surface to disqualify Chiropractic clinics however some are bringing in the CMS definition noted above.

Part II gets into Good Faith Estimates (GFE) and Independent Dispute Resolution (IDR's). Again, the same definitions are used.

The Good Faith Estimate is a requirement that you must provide a good faith estimate of the cost of services or procedures that a patient may expect within your office for a course of care. SO, if this law applies to you and a patient presents to your office and they are uninsured or do not have a certain type of insurance or they CHOOSE to not use their insurance they are eligible to receive a GOOD FAITH ESTIMATE.  Once you determine if the patient is self-pay or uninsured OR you do not accept insurance (cash practice), the patient is entitled to receive an estimate of the cost of services or procedures. You, as a provider, must also give this good faith estimate even if the potential patient does not schedule but requests it.  Remember, your fee for services is your fee for services. This should not be too much different than what you do now, except that you must do it more formally.

So how do you determine if the patient is self-pay or uninsured:

First, as stated above, you should determine if the law applies to you. If so, you MUST ask the patient when they call to schedule if they are seeking to have a claim submitted for services rendered. If they say YES, then you are not required to provide a Good Faith Estimate.

If they say NO, then you are required to provide a Good Faith Estimate if the law applies to you.

If you, as the provider of services, do NOT accept insurance and the law applies to you, then that means that you are required to provide a Good Faith Estimate.

Patients that are enrolled in Federal Health Care programs are NOT eligible for Good Faith Estimates whether you accept insurance or not.

Under the Good Faith Estimate portion of the law, there is also now a dispute process for the patient if they feel they have been charged in excess. If the law applies to you, you are also required to instruct on how they may file this dispute. At this point in time an excess charge seems to be > than $400.00 over the initial estimate. You, as the provider, may also update your estimate as care ensues or if the unexpected should occur during your care. So you do not need to be clairvoyant with regard to your care but you do need to be clear.

If you are providing Good Faith Estimates they should be provided in written form, either on paper or electronic depending on the patient request. If the GFE, is electronically provided it must be in a format that the patient can both save and print. If you opt to paper mail the GFE then it must be postmarked within the required time frame as stated in the law.

The GFE must be provided within 3 business days after request or if a service is scheduled it must be provided no later than 1 business day after scheduling. It must be written in a clear and understandable language. It must also be available in accessible formats and languages spoken. If requested, it can be done by phone or orally in person but must then also be provided in writing.

Most of the requirements for this new law are not too much different than the requirements that were created for HIPAA. Speaking of which, because this GFE will contain PHI (Patient Health Information) it must follow HIPAA regulations. And finally, before we get into what is required in the GFE, remember that this is now part of the patient medical record. As such it must now be maintained with the medical record according to specific state laws, please check your specific state of practice for the exact amount of time that records must be maintained and remember that according to HIPAA it is a minimum 6 years but you are required to maintain the files for the most stringent period of time, so some states may require longer than 6 years and you need to defer to that. 

So what EXACTLY are you going to need to do if you have determined that you need to provide a GFE?

• Patient name and Date of Birth
• Description of the primary service in clear and understandable language and date (if applicable) the primary service is scheduled.
• Itemized list of services grouped by each provider and/or facility
• Diagnosis codes (ICD10), Procedure codes (CPT codes) and the expected charges
• Name, NPI, Tax ID of each provider/facility where the services will be provided.
• Disclaimer that informs the uninsured/self-pay/cash patient that there may be additional items or services that may be recommended as part of the course of care that may be scheduled or requested that are not reflected in the GFE
• Disclaimer that the information in the GFE is only an estimate reasonably expected to be furnished at the time the GFE is issued and that some services or charges may differ
• Disclaimer that the uninsured/self-pay/cash patient have the right to initiate a Patient Provider Dispute Resolution (PPDR) process if the actual billed charges are substantially in excess of the GFE. Instructions on where the individual can find information about how to initiate a PPDR and that if they do in fact initiate a dispute, it will not adversely affect the quality of services provided by that facility. There is a $25.00 fee to initiate a PPDR.
• Disclaimer that this is not a contract and does not require the patient to obtain the items or the services. 

Remember that this has already gone into effect. Please review your policies within your office. 

Once again, regardless of what we state here and regardless of what anyone tells you, we urge you to contact your attorney and state chiropractic licensing board to determine if this applies to you or not. We are providing this information in case it does apply to you or in case your state is forcing you to comply.