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Medical groups report unintended consequences associated with good faith estimate requirements

MGMA Stat - January 26, 2022

Medicare Payment Policies

Billing & Collections

Federal Compliance

Kelsey Haag
The No Surprises Act (P.L. 116-260), passed by Congress in late 2020, established new requirements for providers to issue cost estimate information to uninsured or self-pay patients. These new requirements recently took effect on Jan. 1, 2022, after the U.S. Department of Health & Human Services (HHS) released rulemaking just three months prior to the requirements taking effect.

The uninsured or self-pay good faith estimate (GFE) requirements instruct providers to issue a discounted cash price cost estimate for expected medical services upon request or upon scheduling services for an uninsured or self-pay patient. And while the intent of the new requirements is to increase price transparency, there are significant burdens on group practices that have already resulted.



A Jan. 25, 2022, MGMA Stat poll identified medical group practices’ top concerns with implementing the new GFE requirements. Of those who responded to the poll, 44% identified the disruptions in workflow that will result from the new GFE requirements as the greatest challenge with providing cost estimate information to uninsured or self-pay patients.

The poll had 634 applicable responses.

Uninsured or self-pay GFE requirements

Practices must first identify which patients are eligible to receive the GFE, provide a written cost estimate including a list of services the provider expects to furnish, appropriate CPT® codes, diagnosis codes, and potential additional follow-up services the patient may require with separate scheduling, all prior to a provider evaluating a patient and within a specified time frame. Practices are struggling to understand the requirements from HHS and the Centers for Medicare & Medicaid Services (CMS), as one member stated, “[f]iguring out who needs a good faith estimate is just the beginning of the problem.”

The uninsured or self-pay GFE requirements require major investment by all practices, from small independent groups to large national health systems. And many practices are struggling to find the time, staff, and resources to implement these new workflows. As one MGMA member elaborated in response to the poll, the requirements have created “additional workload for an already thinly stretched staff.”

Implementation challenges

The uninsured or self-pay GFE requirements come at a time when staffing shortages are all too common for group practices. In a September 2021 MGMA Stat poll, 73% of group practices stated that staffing shortages are their greatest concern going into 2022. Without appropriate staff, these new requirements are even more challenging to effectively implement.

Practice level implementation challenges are not the only concern group practices are facing when looking to implement cost estimate processes. Nearly a quarter (22%) of practices state delays in patient care are the greatest challenges they are facing, especially as “patients may not inform us of a change [in insurance status] until they show up for the appointment.” Providers must issue GFEs within a specified time frame. If practices struggle to meet the strict timing requirements, due to unforeseen circumstances, such as changes in patient insurance status, patients may be forced to schedule services farther in advance.

#MGMAAdvocacy

While CMS has provided some guidance for group practices, implementation uncertainties and significant burdens remain. MGMA Government Affairs is advocating for a delay in the enforcement of these requirements to provide group practices with appropriate time to implement new workflows and have sufficient guidance from the agency to comply with the requirements. 

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ADDITIONAL RESOURCES

About the Author

Kelsey Haag
Associate Director, Government Affairs MGMA
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