We're going to jump right into this because we have a lot of material to cover tonight. But thank you for joining us this evening. I know as the session description alluded to, surprise billing has gotten a lot of coverage and attention and you've probably seen it in the news and maybe even had discussions about it. And one of the things we wanted to make sure to highlight tonight was that even though surprise billing is sort of thought of as a sort of issue that arises in the emergency setting or for ancillary services, that there are implications to the legislation that passed to address surprise billing that are going to affect providers more broadly. And so that's what we're going to go through tonight just so that you to make sure that you have an appreciation of all the different requirements that are out there and what a lot of this new terminology means. Also, even when you are functioning as an in-network provider, we've seen payers start to try to exact rates out of their in-network physicians due to this. And so we want to make sure you're familiar with sort of what everything is and what it isn't, so that even if you're in-network and having conversations with payers, that you are well-educated on what all this means so that the payers can't try and sort of pull any fast ones on us. So that's what we're going to try to accomplish tonight. As Megan mentioned, we'll take as many questions as we can at the end. What we're going to do to go through this is I'm just going to give you a little bit of background on the No Surprises Act. Again, that's the legislation that was intended to address surprise billing. Then there are a couple of key concepts that I want to walk everybody through. I think they're sort of the building blocks to this new legislative and regulatory structure that I want us all to be familiar with, and that'll hopefully make the rest of the presentation a little bit easier to digest. And then what we'll do is we'll dive into sort of your big three takeaways. One, what are the patient disclosures that need to be provided now in light of this legislation? What are the notice and consent provisions, and when might you be involved with them? And then finally, you've probably heard a lot about good faith estimates. When are you going to be required to provide a good faith estimate? And then we'll do a couple of final takeaways, and then we'll move to the questions. So before we dive in, just a quick caveat disclaimer that this is for informational purposes, should not be construed as legal advice. And if you do need legal advice or other consulting advice, then you should definitely seek that. But to dive into the presentation now. First, the background. So the No Surprises Act was passed at the end of 2020. And this was part of a larger piece of legislation called the Consolidated Appropriations Act 2021. So you'll find it embedded inside of that. Most of the provisions of the No Surprises Act became applicable beginning on January 1st of this year. But the law laid out several rulemaking deadlines throughout 2021 to support that 2022 start date. I mentioned that because we're going to want to talk a little bit about some of those rulemaking milestones that happened along the way and what they mean. One of those rules that were issued in the last calendar year came out on September 30th. And I want to highlight this one for a minute, and what it focused on. So what was included in this interim final rule were provisions that were related to the federal independent dispute resolution process, sort of how would we resolve payment disputes between providers and payers for services that are covered by this. And it also included provisions that are related to protections for the uninsured. And we're going to talk a little bit about both of those things tonight. However, I wanted to mention, and again, this might be something that you've read about in the news or heard on the news, but there's been litigation that's challenging the federal independent dispute resolution provisions. Basically, the main thrust of the challenge is what the arbiters, the guidance that the arbiters received about how they're supposed to use information that's provided to make a payment determination as part of that dispute resolution. On February 23rd, there is in a U.S. district court in Texas, the Texas Medical Association prevailed in their lawsuit against the federal departments. On February 28th, the departments released updated guidance saying that they're going to comply with the ruling. Then as sort of a placeholder, I would say now, the federal government filed its intent to appeal in that Texas case. There are also other ongoing lawsuits that are still in the queue that were on hold because of the Texas ruling. My understanding now is that the government's likelihood of appealing this is starting to fall apart a little bit, that they might be just sticking with the Texas ruling, in which case we would kind of be in the same environment that we're in at this exact moment in time. But I mention it here tonight, one, because it's likely going to get more attention and you might be hearing about it. But the other thing that I wanted to mention was that these cases are very focused on what happens inside of the IDR process and what the arbiters are supposed to consider and how they're supposed to consider it. My point there is that it's limited in scope. If you see something that says that the government ends up prevailing, that's not going to change most of what we're talking about. We're talking about sort of the baseline requirements and some of the provider obligations that are outside of this lawsuit. Even if you see that litigation start to change course, don't think that it sort of alleviates any of the other obligations that we're going to talk about tonight. So I wanted to mention that just because it's getting a lot of attention. All right, now what we'll do is dive into the key concepts. Again, these are the things that I think are important to understanding as a way to digest the rest of what we're going to talk about and also just help you sort of categorize questions you might have or sort of issue spot particular questions that might come out of what we're going to talk about tonight. So first, just generally, what are the protections here that the No Surprises Act created? These are protections that are limited in their scope based on the scenario, the sort of care scenario that we're going to talk about here. So the No Surprises Act will step in in the cases of emergencies and certain post-stabilization services that are emanating from those emergencies. And then the surprise billing protections are going to apply to non-emergency care, but only when that care is from an out-of-network provider, furnishing that care at an in-network facility. Right? Non-emergency, out-of-network provider at an in-network facility. If you think about it this way, it's trying to create protections in scenarios in which the patient would have a reasonable expectation that their care would be in-network. So that would be an emergency, of course, where they didn't have a choice in terms of their location. For the non-emergency care, what this is saying is, you know, if a patient doesn't do their due diligence and goes to an out-of-network facility, there would be no reasonable expectation that the providers at that facility are going to be in-network. However, this is saying if the patient did their due diligence and they went to an in-network facility, they might have an expectation that the providers associated with that are also in-network. So that's when these protections kick in. So non-emergency care, out-of-network provider who is at an in-network facility. What are those protections? If they kick in in these scenarios, providers can't balance the patients except for a couple of certain exceptions where you provide notice and consent to waive this right. We're going to talk about that tonight. And then there's a cost-sharing protection. And basically what it's saying is that plans can't require the patients to pay more than they otherwise would for a service as if it had been provided by an in-network provider. Now, if the provider is out-of-network and that means they have no contract with the plan, you can envision, let's say a patient has a co-insurance component to their coverage, and it says 20% of the service, 20% of what if there's no underlying contract, right? And so we'll talk about how the law approach is answering that question. The last thing that's important for us to remember tonight is if you, again, look at that number two up top, non-emergency care from an out-of-network provider at an in-network facility. Facility is also very specifically defined. By facility, they mean a hospital, a hospital outpatient emergency department, a critical access hospital, or an ambulatory surgery center. That is it. So this isn't extending to other things that we might consider facilities. And then you would also see from this that if you are practicing at all in the office-based setting, there's no surprise billing patient protection component that goes along with that. Now, there are other requirements that we're going to talk about tonight regarding good faith estimates, which have a different scope, but the surprise billing proper protections are limited to facility-based care. So keep that in mind. And again, it's this very specific list of facilities. The second thing I want to talk about is this term called a specified state law. In general, the legislation is designed to defer to state laws on balanced billing and out-of-network payments from plans to providers. And the way that it does this is that it allows a specified state law to govern, and they've defined a specified state law as a state law that provides a method for determining the total amount payable to the extent that that state law applies. One thing to keep in mind, this is really going to be limited in its application, but if you're in a state such as New Jersey, Virginia, Washington State, that allows ERISA plans to opt into the state's insurance regulations, then ERISA plans have the option to opt into this. But otherwise, ERISA plans are not part of it, just those three places we'll talk a little bit more about that as well. And then the law also, when you're looking at that specific dispute, has to apply to that plan, that issue, or that coverage, right? So if you're in a state that has a law that addresses this, let's say you're in Michigan, and Michigan has a relatively comprehensive law addressing out-of-network payments, but Michigan's law can't capture ERISA plans, then there is no specified state law for that dispute if you've delivered care to a patient covered by an ERISA plan. So then there is no specified state law, the federal law would kick in. It's got to apply to that provider or to that non-participating emergency facility. Sometimes you'll see state regulations that basically carve out emergency medicine and say it's not applicable to them or neonatologists, but it's got to apply to that provider, that facility. And it's also got to apply to that item or service that's involved. If you're in New York, or I think there are a couple of other states that have a dispute resolution mechanism, but you can't get into it unless the dispute is over a certain payment amount. Well, New York, that number is $714 this year. If you're below that, their dispute resolution process can't capture it, and therefore there would be no specified state law for that item or service. So it has to apply to sort of every component. And then if the specified state law doesn't capture that dispute, then the federal provisions will kick in. One thing I will also mention before we jump to the next slide, there's nothing about the No Surprises Act that freezes all of this in time. So states may choose to alter their current state laws and their regulations regarding this. And so staying on top of those changes will be important. The Commonwealth Fund recently put a map together, and basically what this is showing you is in Navy, the states where there is no specified state law at all, and therefore you would only be dealing with the federal provisions, the federal protections that we talked about. Now, again, that's going to be limited to emergencies and non-emergencies by out-of-network providers in network facilities, but it would just be that regulatory scheme. In the states that are there in orange or peach, what that's saying is that there is a specified state law that's in play there. The problem here is that doesn't give us a lot of clarification because each of those state laws are only going to apply in certain circumstances. So the way that I would really digest this map is basically to say, if it's a Navy state, I know I'm just dealing with the federal rules. If it's a peach state, I'm trying to figure out whether this actual dispute on a case-by-case basis lives under state rules or lives under federal rules because in each of those places there's going to be two different pathways depending on the scope of the state law. CMS also just put out a list that coincides with this. So again, if you're in one of these states, you're only worried about the federal issues. Then they called it the bifurcated approach and listed these states here. They also listed the state process where that's going to govern disputes, but I would highlight their asterisk that they included here, which in a nutshell says, but these states can't govern ERISA plans. And so ERISA plans, self-funded plans, are going to live under the state rules. So really, if you think about it, especially given the volume of services that are delivered to patients that are in ERISA plans, really you can think of these two groupings, the bifurcated process and the state process, as a bifurcated process. Some of them are going to be subject to the state law. Some of them are going to move under the federal regulatory scheme. So that's the sort of state federal component to this. The next thing I want to set the stage with is the qualifying payment amount. This is the QPA. This is a concept that was created by the No Surprises Act, and it is a term that is given to what is really the median contracted weight. For a particular item or service. And the way that this works is that each plan is going to set this up, and they're going to set it up for their different types of products. So they're going to have a QPA for an item or service that's in the individual market, a QPA for that same item or service that's in the group market, and then a QPA for that same item or service that's for their ERISA or self-funded plans. It's going to be based on their contracts in 2019, and then there'll be an inflationary update that adjusts that median contracted rate from 2019 to get us up to the current year. So what is this QPA used for under the law? One, it is used as the anchor for the patient cost sharing protection. So before when I gave you that example of the patient coinsurance of 20%, and I said 20% of what? It's 20% of this, 20% of the QPA. This number is what serves as the replacement for the contracted rate, since you have no contracted rate if you're out of network with that plan. The second significance of the QPA is that it's used as a reference point as part of the federal independent dispute resolution process. So if it's a dispute that's covered by the federal rules, and you're eligible to go to the federal IDR process, the QPA is one of the things that the arbiter has to consider when they're trying to figure out what the payment determination for that dispute is going to be. What I really want you to take away from this is that that's it. That's all that the law says that the QPA must be used for. And I mentioned that because we have seen plans that are basically taking this and saying, going out to their in-network providers and trying to lower their rates, and saying that the law says that we have to do that now. That is not true. The QPA is only for purposes of patient cost sharing, and it is only to be used as a federal IDR payment determination point of consideration. It is not mandated that they pay you this amount anymore. There are some criticisms of the rule that implemented the QPA, even when it's being used properly. There's some concern that it's not reflective of actual market rates. They're not weighted. So if you have a contract that has 100 providers that are inside of it, and another one that has five, those contracts are the same for purposes of selecting the median. And also, it's tough to know how the plan calculated it or selected that QPA. So there's some criticism there. But just keep in mind that the role of the QPA as the law has set it out to make sure that plans don't try and misappropriate it in their negotiations with you over your contracted rates. And then finally, just a little bit more about that federal IDR process. It's only going to be available for those items and disputes that we talked about before, where there's no state law. And it is then either an emergency or a non-emergency service by an out-of-network provider at an in-network facility. Nothing that happens in the federal IDR process is going to affect the patient's cost sharing liability. that's firmly anchored at the QPA. If you go to IDR and the IDR determines that the provider, the provider's payment request is the right one, that's not going to change what the patient pays. They're detached from each other now. There are fees to go to IDR in the event of a dispute. Those are listed there. They might change by year, but that's a consideration. How much do you believe you are underpaid in? Is it worth it based on these fees? There are other things that the arbiters aren't allowed to consider, which are listed here, the usual customary charges, billed amounts, public pay rates. There's a portal that they've created to facilitate a lot of this that you can access at that CMS site that you see listed there at the bottom of the page. I would be interested to hear if anyone has had to engage on this process yet, but we're not going to spend a lot of time on this piece of it for the rest of the evening because my hope is, and my thinking is, is that you won't find yourself in IDR all that often. If you are and you have additional questions, please let us know and know that there's additional background and information available on this topic. The last thing is just a quick primer on the good faith estimates, and then we're going to dig into some components of it a little bit more. What I really want you to know here at the outset is that there are three different good faith estimates that the law contemplates. If you hear about it or you have a question about it, make sure that you're categorizing which good faith estimate it is that you're talking about or have a question about. One is that they're in those surprise billing proper scenarios that we talked about, again, emergencies or non-emergencies by an out-of- network provider at a network facility. There is going to be a good faith estimate that you would provide to the insured patient if you are going to provide them notice and they were going to consent to waiving their balance billing protections for non-emergency services. In the event of that notice and consent process, you would just be providing the good faith estimate for the services that you were going to provide. We're going to talk more about that. The second one is, again, in that sort of surprise billing context, and it's a good faith estimate for insured patients and giving that good faith estimate to the planner issuer. This is not required yet because they haven't issued the regulations. They're behind schedule on this. The idea here is that for non-emergency services that they want to create a mechanism in which plans are able to generate advanced EOBs for patients so patients will know what their actual out-of-pocket is going to be if they decide to go with this out-of-network provider. In order to do that, the plan would need to know from you what is your good faith estimate for this service that the patient is contemplating. There will be this good faith estimate for insured patients component outside of the sort of notice and consent mechanism we're going to talk about. Know that that is on the horizon. The third, and if you've heard about these good faith estimates, this is probably the one that you've heard about, is a good faith estimate that you would be required to give to uninsured or self-paid individuals for all reasonably expected provider charges. We're going to talk more about that because that is outside of that surprise billing context that we talked about. We're not talking about emergencies. We're not even talking about it being limited to non-emergencies at in-network facilities by out-of-network providers. What we're talking about there is a good faith estimate for a scheduled service to any uninsured or self-paid patient. There are really broad implications to that, and we're going to spend some time talking about that in more detail in a little bit. That's to set the stage for the rest of this. The first thing that I want to talk about because it has broad application to providers outside of an immediate provision of care to an out-of-network or by an out-of-network provider to an insured patient, and that's patient disclosures. There are patient disclosure requirements that are associated with the No Surprises Act. In general, basically, it's just a requirement that providers and facilities are making patients aware of their rights and protections. That means that we need to be letting people know about the federal restrictions on balanced billing, any applicable state laws against balanced billing, and information on who they should be contacting at the state or federal level if they believe somebody is in violation of these rules related to balanced billing. This is what's important to note here. These requirements here to share these disclosures apply to all providers unless you never, ever, ever provide a service in conjunction with the facility. Again, facility as we defined it at the beginning. If you are providing care at a facility, that means that you are seeing patients where the No Surprises Act could potentially provide protection, which means you need to be providing this upfront disclosure. I'm going to show you what that looks like. There are a couple of methods of disclosure that are required. The first is that if your practice has a public website, the website has to include these disclosures. If you practice at a hospital, they cannot meet this requirement for you if your website is separately maintained. You must have these disclosures on your website, again, if you see patients at all in a facility. The second method of disclosure is that you have to place a sign posted prominently at the location of provider in a central location, which they define as where you schedule care, check in, or pay bills, except that you are allowed to enter into written agreements with the facilities at which you practice, basically contracting with them to take on this responsibility. Note that it has to be in writing, and that you would have to have this written agreement with every facility that you practice at, so that no matter where your patients are, they're going to see this sign. The last is a one-patient disclosure to patients that the protections might apply, but again, here, you can enter into a written agreement with facilities that you practice at where the facility is going to take on the full responsibility for the provision of that one-page disclosure. What's important to note here is, one, on the first one for the public website, that's something that your practice has to take care of if you have a public website. Then for two and three, even if the facilities that you practice at are going to take on this responsibility for you, you still need to go through the effort of making sure that there's a written agreement that shifts that obligation to the facility to remove the obligation from you. There's some affirmative actions that need to be taken here for these patient disclosures. Again, you don't have to do them if you only have an office-based practice, but if you see patients at any facility, which I would assume are most folks that are on the call tonight, then you would have to meet these patient disclosure requirements. On that one-page disclosure, if you're not going to have a written agreement with the hospital to take care of it when you are required to furnish it, you have to make sure that it's done under certain timelines. It can't be any later than the date on which you seek payment from the individual, which includes copayments. If you don't make a payment request, then no later than when you would submit the claim to the patient's plan. You can always share it earlier if you want at the point of scheduling care. You're allowed to do that, but there are some otherwise timelines that you have to meet there if you're going to be the entity in charge of providing that one-page disclosure. There is a model disclosure that the agency made available, which is available in a zip file at this link that you see here. If you have another document you want to incorporate these things into, or you already had a disclosure that you think meets these requirements, you're allowed to use those other documents. This is only a model disclosure. For certain other things we're going to talk about tonight, there are standard required documents, but here it's a model disclosure. You can use this or use the content in other disclosures that you might already have if you're going to take on these responsibilities. It would also help you, if you do have that public website, know what you need to post. That's the patient disclosures. The second are the notice and consent provisions. Here, what we're talking about is that scope that we started out with. In certain circumstances where there is an emergency and then post-stabilization services are provided after the emergency, there might be an opportunity to use the notice and consent provisions. In almost all non-emergency care from out-of-network providers and in network facilities, you'll be able to go through the consideration of whether the notice and consent provisions are available to you. Basically, what it is is that it allows the patient to agree to receive services from an out-of-network provider at an in-network facility and wave their balance billing protection. If you are seeing a patient at an in-network facility and you're out of network and the patient says, I really want to stick with you, this basically says, okay, here are your rights. Then this is what you have to sign if you'd like to waive those protections. Then you would be able to continue to balance bill that patient. It's only going to apply in scenarios where the patient is eligible for the billing protections because otherwise the protections are inapplicable. There's nothing to waive. That's how these provisions would present themselves. Again, in these scenarios, then if this is potentially available to you, there are some requirements. This is one of those areas where you have to use the document that the agency is providing if it's covered by federal law. It also has to be provided at least 72 hours in advance. If you're scheduling care in a shorter period of time than that, you have to make sure that they have this notice and sign consent at least three hours in advance of that item being furnished or service being furnished. As we mentioned during the good faith estimate primer at the beginning, here where you're provided a good faith estimate, you're only having to provide an estimate for the charges that you intend to submit to the plan for this item or service that the patient is waiving their balance billing protections for. You cannot use this waiver in emergencies, unforeseen urgent circumstances for ancillary services rights or radiologists, labs, they can't ask patients to waive their protection, assistance at surgery can't, all of those sorts of areas where it wouldn't be reasonable to expect the patient to have done their due diligence and know that they might be encountering an out-of-network provider. The other thing here, and this one's important to keep in mind, you can only ask the patient to sign this and therefore continue to balance bill the patient if there's somebody else that's in network at the facility. What they're saying here is they don't want the patients to be held hostage, that you're the only one there and they have to go somewhere else. If you're the only one there that's not in network, they want to make sure that the patient has a choice. So again, you can't use this if there's no participating provider at the facility to furnish this. They're trying to sort of, I think, highlight that this is truly supposed to be the patient's choice to want to stick with you and they have other options that are reasonable. As I mentioned, there's a standard notice and consent form. It's required unless there is a state-developed document that meets the specifications that also is designed to conform with the state rules related to all of this. If you look at this link here, there are instructions that are included with it that will help highlight some of these requirements that I just laid out, which I know is a lot of information. So be sure to check out that document from the Centers for Medicare and Medicaid Services as well. And then the last component, before we switch to just a few takeaways and then try to answer some questions, is when are you required to provide a good faith estimate? What I want to focus on here is that third good faith estimate element that I laid out at the beginning. And these are good faith estimates for uninsured or self-pay individuals. This is much broader than that sort of surprise billing scope that we talked about. So again, this is not limited to emergencies and non-emergencies that are services that are provided by out-of-network providers at in-network facilities. This is for all services that are scheduled to anybody who is uninsured or self-pay. And self-pay is also going to be a patient who has coverage who says, I'm not going to submit this claim to my plan. They would become self-pay, and this would be captured by the rules we're going to talk about. Think about patients. Maybe you've encountered patients who are benefiting from acupuncture, and they have no intention of submitting that claim to the plan. That patient becomes self-pay in that circumstance, and the provider scheduling that service would have to provide a good faith estimate, and the contents of which we'll talk about. Again, this is for scheduled care. And also, I would note that it's upon request. So if the patient asks for it, even if you haven't put them on the calendar yet, if they ask for it, then you're required to provide it, assuming it's for a non-urgent service. There are two components to what we're going to talk about here that the law creates. One is the requirement to provide that good faith estimate. There's a model notice. I'll give you the link to that. But if you've been doing this previously, and you have another document that works, you can continue to use that. And then there's going to be a patient-provider dispute resolution process at the federal level that's new. Some of you might be in states where this already exists. But basically, there's no plan involved here, right, because the patient is uninsured. And so it creates a dispute resolution when the patient thinks that they shouldn't have to pay as much. But this dispute resolution process is linked to the good faith estimates. So we need to start there to understand that, to better understand the scope of the patient-provider dispute resolution process. So a couple of things to understand here when it comes to figuring out what your responsibilities might be. The regulations create this concept, which is a convening provider or facility. I'm going to tell you more about what that means, but just know that we're going to contrast that with a co-provider or a co-facility. So first, let's look at the convening provider. The convening provider is basically the entity or the practice that receives the initial request for a good faith estimate or the person who is responsible for scheduling that item or service, right? So if you're scheduling this item or service, even if there are other ancillary services that are involved, you become the convening provider. Then there are co-providers. Co-providers are the providers in the facilities, other than the convening facility that furnishes an item or service, that are customarily provided in conjunction with the primary item or service. So let's say you had a patient that you scheduled to come in and see you for an office visit, and you have a pretty good hunch that it is going to require imaging, right? Those imaging services would be sort of a co-provider, I guess, if you were going to send them to an imaging center or a co-facility. And if you sort of think about it in that context, I think these obligations will start to make a little bit more sense about how this works. So the good faith estimate in these situations needs to be made for all services or items that are reasonably expected. So if you're that convening provider, right, you scheduled the service, you have to reach out to all of the co-providers and co-facilities within one business day and request a good faith estimate for what their services are going to require. And then they're going to have to report that back to you no later than one business day after they've received that request, right? So in the scenario we talked about before, you schedule the service, you know that there's going to be imaging required, you have to reach out to the radiology practice or imaging center and get their estimate for what you think is reasonably expected for, you know, what you scheduled this case for. If this is just, let's say, an office visit and you have no information, it's a new patient, then anything that might result from that wouldn't have been reasonably expected because you didn't have any information. So even if the patient does show up for the office visit, you say, yeah, we need to send you to get some imaging done, you're not going to be on the hook for having included that in the good faith estimate because you couldn't have expected that that was going to be resulted because you didn't have the information. But if you do, you need to reach out to these co-providers and co-facilities. What does reasonably expected mean? It's reasonably expected to be provided for the primary item in service and all items or services reasonably expected to be furnished in conjunction with that item or service. One thing I will note, if we think about things like therapy, if you know that there is something that the patient is going to need, but that somebody else is going to take care of the scheduling, right, So you're not scheduling it, but you know that the care is involved at the time that you're scheduling your interface with the patient, then you have to create a little carve out in that good faith estimate that says you're probably going to need other separately scheduled services. I can't tell you how much that's going to cost, but you should know that there are probably going to be other costs that are associated with sort of the full package of services. The other thing I would mention is for anything that's recurring, if you, again, this is at the moment at which you schedule the services, if you know that there is going to be something provided, reasonably expected to be provided in conjunction with that scheduled service, and it's recurring, you also have to include recurring items and the good faith estimates that would go along with those recurring items or services. So keep that in mind too. There are deadlines for providing this to the patient. So I tried to schedule it here in the context of the point of reference that I think is most important. So to know your timeframe, it's a question of when you're scheduling it relative to when the patient is going to come in. So if you've scheduled it at least 10 days before you're going to furnish it, then you have three business days after it's scheduled to get this good faith estimate to the patient. That is a quick turnaround, right? Especially if you're the convening provider and you're reaching out to the co-providers and asking them for their charges, they have to get that back to you so that you can populate the full good faith estimate. So even in that less stringent timeline, it's still pretty tight. Now, what if you've scheduled it, but it's only in the next three days, right? In the next three to nine days. Then you have to get this good faith estimate to the patient one business day after scheduling it. So now it's really tight. And then what do we do if it's furnished in less than three days? You've got them on the books, you've scheduled them, the patient's going to come in tomorrow, you had an opening. In those scenarios, there's no good faith estimate that's required. Three days or under, they just determined that it was not feasible. So really, this is going to kick in for scheduled care, for uninsured or self-pay patients, for anything that you schedule, that's scheduled for at least for more than three days out. Also, remember that if the patient just asks for it, right, even if you haven't scheduled it, if the patient asks for it, then you are in that top bullet timeline where you need to get it to them within three business days. The other thing that I'll note, just from sort of a compliance operational standpoint, the good faith estimate becomes a part of that patient's medical record. And if you're the convening provider, right, the person who scheduled this and coordinated the delivery of the good faith estimate, that has to be retained in the patient's medical record for at least six years. So keep that in mind, too, as you're thinking about your compliance strategies related to this and paperwork. A couple of resources to share with you here. There is a link there to the patient's notice of a right to receive the GFE that you can provide to patients when these scenarios arise. The model GFE that I mentioned for uninsured or self-pay individuals, that is a zip file. I apologize. I couldn't get you a link right to the document, but that will get you pretty close. Again, here, it's a model document. You can use it, but you are not required to. So if you otherwise meet the requirements that are associated with this, you could use it in another format, or maybe you already have a document that does this and you would be allowed to continue to use that. And then finally, there are a lot of questions about this because of how broadly applicable it is to so many, to basically all items and services that are in emergencies for uninsured or self-pay individuals. And so CMS has been putting out some frequently asked questions that help bring some clarity to this. So there is a link to those FAQs as well that I would highlight that might be worth reviewing. That will cover some of what we talked about tonight, but I think is a good resource to keep on hand. And then finally, on this piece of it, I mentioned that patient provider dispute resolution process and how it's inherently linked to the provision of the GFE. So when you're required to provide that good faith estimate, if what you ultimately bill the patient is more than $400 over that good faith estimate, then the patient is eligible to take that provider or facility into a dispute resolution process. Now it's for that specific provider. So let's say you scheduled the service as the convening provider, you knew there would be imaging, you get the good faith, you know, the good faith estimate from the radiologists and the good faith estimate says $200 for that piece of it. And the radiologist goes on to bill the patient for $800. The patient can't drag you into that. They would drag the radiology practice into that. So it's $400 for the specific item or service that you are responsible for on that. But in the reverse, right, if there is another provider that's the convening provider and asks you for your charges, and your ultimate billing is $400 more than what you told them to include in the good faith estimate, then the patient could take you into this PPDR process. The patients have 120 days of getting their bill to initiate this process. Once you have received notice that a patient has started this process, you can't move bills into collections. And you have to suspend accrual and late fees. But I think that this is really an important piece is that you can still negotiate a settlement amount. So you're only going to go all that way if you're sort of demanding that the patient pay it. If you agree to the patient saying, I just want to write a check for what you told me it was going to be in the good faith estimate, you can do that. The I would say one of the more likely ways that you might find your way into this PPDR process is if, let's say in the course of that visit, you end up providing a service, a treatment, right. And there's a charge for that. But it's not something that you could have known beforehand, it wasn't reasonably expected. So it wasn't on the on the good faith estimate, right. So it was it was reasonable and necessary, it was medically necessary. And now there's this extra charge. And if that is is a significant amount of money, the patient may take you to pp to this PPDR process, you would be able to go into that dispute resolution process and say, it was not reasonably expected. This was a new patient office visit, there was no way I knew what was going to be the diagnosis or the treatment there. So there's no way I could have talked about any other services than an EM visit, you will have that opportunity there. That to me seems to be probably the more gray area when there are treatments that you can provide on the spot and you do it. But you couldn't have known what those were going to be when you provided the GFP. Those might look like extra or new charges to the patient. But you know that you couldn't have known in advance that you were going to provide that. So to wrap up on the full presentation here tonight, and then start to answer some questions in the the nine minutes that we have left left here. First, the departments have discussed enforcement discretion. And for states that are taking on the enforcement responsibility here, they've asked states to proceed similarly, similarly. But I would sort of operate with January 1, as of this year as as the date at which all of this was required. And if you're not meeting these requirements, you're opening yourself up to some compliance vulnerabilities. There are more regulations coming to implement other provisions of the law, they were already supposed to be in place, but they're not there. They're going to be new requirements for the plans and what they have to put on the insurance cards for their network directories. They're going to be accuracy requirements they have to meet, as well as some other provisions. Also, I think one of the more gray areas and all of this is if you think of that map that I showed you in the orange or peach states, whether the state or the federal law is going to govern, here are a couple of resources that I would look at. You could have the state or federal government enforcing these laws, you could have a state or federal government speaking to balance billing with their specified state laws, you could have a state or federal mechanism for this patient provider dispute resolution process. If you go to that link that you see that I provided there, there is a letter that the agency sent to each state. It will start to give you information of how the federal government views their role versus the state roles in all of these issues. I wanted to provide that link so you could take a look at the letter that went to your state enforcement agencies regarding all of these issues. Lastly, just to go back to that lawsuit piece that I talked about at the beginning, again, the Texas Medical Association prevailed. There are a couple of other lawsuits that are in queue here. Again, remember that that is really laser focused on the federal IDR and QPA issue. Even if the story were to change with regard to these lawsuits, the patient disclosure requirements we talked about wouldn't change, the notice and consent requirements we talked about wouldn't change, and your obligation to provide a good faith estimate to uninsured patients wouldn't change because those lawsuits aren't calling into question those three requirements that we talked about tonight. With that, I will go ahead and stop there and turn it over to Megan and Carolyn to see if there are any questions. Megan Caryland Thanks so much, Bob. That was a great presentation. The presentation obviously included a ton of information and we are going to have a recording available. I'm also going to put a contact email in the chat. If you do have follow-up questions after today, please feel free to email us. We did get a couple of questions through the chat. I'm going to read those off starting with the first one. This was in reference to a pretty recent slide regarding the good faith estimate. If a provider simply writes an order for something like an MRI, but does not schedule it, the provider would not need to do a GFE. We give the order to the patient and they schedule themselves or we let the facility know that an order is written. Bob Goulais So I would agree with the first positioning of that. So if you think of the moment in time that you scheduled the service, that is the moment in time when you might be on the hook for providing a GFE. At that moment in time, you would not know that you were going to write that order. If then the patient comes in for medical and you write the order for what they're going to separately schedule, you do not need to provide them with a GFE for that. When they go and they go to schedule it, that provider will be on the hook for providing a GFE for that service. The only way that that would be different is if for some reason when the patient scheduled the service with you, you would have reasonably expected that this was going to happen because of what you already knew, either that they were an established patient or you had met with them already and you were scheduling something where you knew this was going to be provided in tandem. But if you are not scheduling that service, and again here, if you look at that bullet at the bottom of the slide that I pulled back up, what I'm hearing in that question is that that's a separately scheduled service and therefore you would not need to do that. Thanks, Bob. I'm going to move on to the second question. This is a little bit of a longer scenario. I was on call at our inpatient rehab facility during a recent holiday weekend. A self-paid patient decided not to discharge on the day agreed upon with administration prior to the weekend. There was no medical reason to delay her discharge. I advised the patient that she may incur additional charges without a specified amount given, and she actually filed a complaint against me with the Joint Commission because she felt I assumed she was indigent, which I did not. Would I be required to provide that patient an estimate as to the amount she may be charged by the facility for staying longer? I'm going to start here with the disclaimer that this is veering into legal advice terrain and I can't give legal advice, but I'm going to do my best to sort of answer this in sort of what I'm hearing. In that scenario, I don't hear you springing into the role that we have defined here under the rules as the convening provider. You know that they're going to have continued charges, but I'm not hearing a scheduled item or service. I'm hearing an ongoing service that's going on longer, and so I don't think that you would bear the responsibility to provide a good faith estimate. Now, of course, in any of these scenarios, there's nothing that prevents you from doing that if you'd like to, but I'm not hearing anything that makes me think that you're the convening provider. There might be in that setting a facility requirement to provide one, but I'm still not hearing a scheduled item or service. The continuation of an ongoing service is not sort of contemplated by these rules, so I think you would be okay. It's probably a little bit of semantics, but if the patient stay is no longer medically necessary, there's sort of reason to believe that the plan isn't going to want to cover it, which would mean at that point in time that the patient is self-pay because they would not have perhaps coverage for that, so that's neither here nor there for whether you need to provide a GFE, but I just feel like that's a little unfair for that accusation to be hurled at you that you're making assumptions about their willingness to pay. If you have a good reason to believe that the plan isn't going to cover it, that patient is in fact self-pay at that point, but still here, I don't hear a scheduled service, so I don't think you need to provide a GFE. Thanks, Bob. We have one more question that we can try to get in in the end of the session. What is the standard for arbitration, mean or median reimbursement rate for a procedure or service? So on arbitration, one, some states have arbitration. That's going to continue as is unless they change their rules, so if you've been exposed to this at the state level, that's going to be different, but if you are eligible to go to federal IDR, the federal independent dispute resolution process, federal IDR is set up to be baseball-style arbitration, which is a term you might have heard, and basically what that means is that each party submits an offer and the arbiter has to pick one of the two. They can't go in between. They can't do anything else, so the idea here is that the parties will moderate their offers in the hope that the arbiter will select it, so the payment determination is going to be either the offer that the plan submitted or the offer that you submitted, and then, and this is where we hone in on where the lawsuit sits, the question is what does the arbiter consider when they try to figure out which of those two offer, you know, which of the two offers they're going to select, and they're going to consider that QPA factor, but also you can submit things which are, you know, the patient acuity, why this, you know, why the delivery of this service might have been more intense and required more resources, or your contracting history with other providers. This is fair with other payers that I contract with, or perhaps you used to be in network with that payer and you had a contracted rate with them and you just submitted that as your bill charges. You could say, I'm, this is my offer because this is what that payer used to pay me, so there are things that you can put in front of the arbiter to argue for your offer, but they have to pick one of the two. They cannot make up their own number. And there was a follow-up to that question regarding the above question of arbitration. This relates to services like urgent non-participating radiologists consulted by a PM&R doc. What is the position of AAPM&R on the arbitration procedure? I'll just say we don't currently have a position on that, but Bob, is there any clarification you can provide based on that? Yeah, the only thing that I would add is that I hope, like I said at the beginning, that you will find yourself in this circumstance infrequently, because again, IDR is limited to those protection scopes that we talked about at the beginning, so emergency post-stabilization or non-emergency by an out-of-network provider at an in-network facility. So first off, if the facility is out-of-network and you're out-of-network, none of this applies, so that's going to take a bunch of scenarios off of the table. Second, right now, let's say you are in-network, or you are out-of-network and the facility is in-network, a lot of you might choose to go through that notice and consent process where you say to the patient, I'm out-of-network, there are other in-network PM&R specialists here that you could see, and they say, no, no, no, I want to stick with you, and then you're going to share with them the notice and consent, and they're going to sign it, and they're going to say, go ahead and bill me what your good faith estimate says your expected charges are for this. And if you go through notice and consent, that stops the IDR process as well. You won't end up in IDR because the patient has basically waived their right to be balanced billed, and now you're in a payment dispute with the patient, not in a payment dispute with the plan, which is what the IDR process is intended to resolve. Thanks so much, Bob. This was great. That brings us to the top of the hour, so we'll end the webinar here, but I did put our health policy email in the chat, so please feel free to email us if you'd like, and as I mentioned, I will get an email to all registered attendees with the links that Bob included in his presentation. Thank you so much for joining us tonight.

surprise billing

No Surprises Act

providers

balance billing

patient disclosure requirements

good faith estimate

uninsured patients

dispute resolution process

litigation