Good evening and welcome to tonight's webinar on the No Surprises Act Requirements, Good Faith Estimates for Uninsured and Self-Paid Patients. My name is Megan Rupp and I'm the Telehealth and Payment Innovation Specialist at the Academy. And I have the pleasure of introducing Bob Jasek and Cindy Moon who will be leading tonight's session. Bob is the Vice President for Coverage and Payment Policy with Heart Health Strategies. Prior to joining Heart Health, Mr. Jasek served in regulatory advocacy positions at the American College of Surgeons and the American Association of Orthopedic Surgeons. He also spent some time working in hospital consulting, working in the advisory board company in D.C. He's also worked in various positions in the federal government, serving in positions at the U.S. Department of Health and Human Services, as well as the CDC Office of General Counsel. Mr. Jasek received his law degree from Emory University and completed his bachelor's degree at the University of Michigan, Ann Arbor. Cindy Moon is the Vice President of Health Care Payment and Delivery Reform at Heart Health Strategies. And prior to joining Heart Health, Ms. Moon worked at the White House Office of Management and Budget where she advised on policy solutions affecting the Medicare program, including those affecting physician payment. Ms. Moon also worked at the Health Plan of San Mateo where she managed Medicare Advantage and Part D operations, as well as led plan activities across several priority initiatives. Ms. Moon earned her Master of Public Policy and Master of Public Health from the University of California at Berkeley and her Bachelor's of Arts from Harvard University. Before we begin, I would just like to review some of our housekeeping notes. The webinar will be recorded and made available along with the ability to see that on our online learning portal. It will be in about a week. And for the best attendee experience, your microphone has been muted, but please know that you are able to ask questions and we will follow up after Cindy and Bob's session with a Q&A portion. And to ask any questions, you'll just enter your question into the Q&A box. And this is just a picture to show you what that would look like. I'm going to turn this over to Bob to begin with our session. Thank you, Megan. Good evening, everyone. Thanks for joining us, or if you are watching the recording, thanks for taking time to tune in and hear our discussion. Just want to start with a quick disclaimer that tonight's presentation is for informational purposes only and shouldn't be construed as legal advice. And you certainly want to get outside assistance where needed to get opinions on financial or clinical arrangements. And we also want to mention, particularly for the people who are watching the recording, that this reflects information that's been made available by the federal government as of today's date, the presentation, and that's subject to change, obviously. And we'll talk about a couple of things you should keep your eyes out for where things might indeed change. So with that, we can go ahead and jump in. Just a quick overview of where we're going to go tonight. I'm just going to speak for a couple of minutes to orient us as to how the good faith estimate fits into the bigger picture. But we're going to spend most of the night talking about good faith estimates, and Cindy's going to walk us through that, as well as sort of the consequences to GFEs that are not accurate, good faith estimates that are not accurate, and the patient-provider dispute resolution process. And then we'll wrap up with some key takeaways. And while we should have some time left for Q&A, and again, use the Q&A feature on your screen to submit questions, and we'll loop back around to those at the end of the presentation. Next slide. So just really quickly, the NSA, shorthand for the No Surprises Act, was passed at the end of 2020 in the Consolidated Appropriations Act of 2021. And this legislation was directed at all of the attention and the trouble that was arising from surprise bills that were generated because of out-of-network services. I often like to say that it's not really a surprise bill that the provider is submitting a bill for services rendered. What's a surprise is that the patient has insurance and the insurance isn't covering or paying for it. And so this is meant to address those situations. I like to refer to those as sort of a surprise billing proper situation. So we think of emergencies or perhaps non-emergency care or perhaps non-emergency care where someone might be having spine surgery and they're already in surgery and then the anesthesiologist is out of network. Those are the surprise billing instances that the law really came into being over. And what it basically did was it said, if your state already addresses those situations, that's fine. And the state law will continue to govern. But if it doesn't, or if state law can't regulate a health plan like in the cases of ERISA plans, then we're gonna create a mechanism to address these situations. And so there are patient protections that are involved and there's a new independent dispute resolution process to basically try and come up with the payment rate, a payment determination where there's disputes between providers and health plans. There's a lot happening inside of that law. And if you see the QR code on your screen, that is gonna take you to the AAPMNR landing page where we did a presentation that dives more into some of those details. So we're not gonna rehash those items tonight, but we did wanna let you know that that was there and wanted to make sure that you understood that the good faith estimate component to this came sort of part and parcel with that. And for a lot of people, they've heard a lot or seen a lot of coverage about sort of surprise billing and think that it's limited to emergency providers, hospitals or ancillary providers, pathologists, radiologists, anesthesiologists, but the law actually expands into other areas that are not those out of network situations, just those out of network situations. And that's what we're gonna talk about mostly tonight. It's most likely that you're gonna find yourself living with these rules and having to navigate them more often than some of the surprise billing proper stuff. And that is related to the good faith estimates that are required by the law, as well as these surprise billing protections. Next slide. So the first thing I wanna orient you to before turning it over to Cindy to walk through these requirements is that there are three different types of good faith estimates that the No Surprises Act contemplates. So I wanted to orient you to those and make sure that if you have questions about them or if you're doing research about them, that you're putting the good faith estimate question in the right bucket. So the first one is that in those surprise billing proper scenarios where you have an insured patient, it's a non-emergency, there's a mechanism that the law created that basically says, if the patient wants to stay with an out-of-network provider and waive their cost sharing, their balanced billing protections, that they're allowed to do that. But in order for the patient to sign that notice and consent to be treated and billed by an out-of-network provider, the provider has to give a good faith estimate of what that service is gonna cost. That's different than what we're gonna talk about tonight separate from the provisions that we're gonna spend time focused on here. The second is a different version of the good faith estimate. Cindy's gonna talk more about this. I mentioned it as sort of a placeholder because all of the information isn't available yet, but eventually the law will require that for insured patients that you see that you will provide a good faith estimate for all of them in certain situations so that the health plan can generate an advanced DOB. And the idea here is that we're trying to get to a world, or at least Congress was envisioning that we would get to a world where patients were gonna finally start to know what their out-of-pocket costs might be in advance. And the only way that you could get there is if the provider tells the health plan what the expected charges are or what the good faith estimate is for their services for something that's insured. That's gonna be a big deal, but there's no regulations to date. And Cindy will spend a little bit more time on that. But what we're gonna focus on tonight is the good faith estimates that are required by the No Surprises Act that you provide to uninsured or self-paid individuals for all reasonably expected facility and provider charges. We've already seen rulemaking on that. There's additional rulemaking to come. There are a lot of questions up in the air that might result in more details being released. So that's what we're gonna focus on today. And probably of all the things in the No Surprises Act is the most likely thing that you've encountered thus far. And if you haven't yet, you wanna be paying attention to it. And that's where we wanted to focus on it tonight. So with that, next slide. And I will turn it over to Cindy. Great. So as Bob mentioned, we're really focused on those good faith estimates for uninsured or self-paid patients. And again, reiterating Bob's point, this does not apply to the typical or more traditional surprise billing elements that Bob mentioned earlier, which may not apply to many PM&R physicians. But if you provide care to an uninsured or self-paid patient, then these requirements will apply for those patients. And again, as Bob mentioned, these requirements went into effect starting in January of 2022. So these are steps that folks should already be taking. And I think the first thing here to understand is whether the patient is uninsured or self-pay. And in fact, HHS requires providers and facilities to determine the status for the patients that they treat. A patient is considered uninsured if they do not have benefits for an item or service under one of these four categories listed here, a group health plan, a group or individual health insurance coverage, an FEHBP health plan, or a federal healthcare program. So providers are required to ask their patients about whether or not they have this kind of coverage. And if not, then the patient would be considered uninsured. If patients do have coverage under one of the first three bullets, so they are insured, the provider also has to ask if the patient is seeking to have a claim submitted. And if not, the patient would then be considered self-pay. So there we have the definition of uninsured and self-pay. And if you have a patient that meets one of these categories then GFEs do have to be furnished to these patients under two situations. First is when they are scheduling care. And second is if they request a good faith estimate or request information about costs. A quick note, you might've noticed that I didn't include that last bullet, a federal healthcare program underneath that self-pay consideration. And that's because those programs like Medicare, Medicaid, you know, other federal programs, they have their own protections against high medical bills. So GFE requirements generally don't apply to patients in those programs. All right, next slide, please. So what are GFEs? Basically, they're written documents that outline the patient's expected charges for a scheduled or requested item or service. These services could be provided over a period of care that could include just a single day or multiple days, but it really depends on kind of what the services are that are included in the GFE and when those services are furnished. And to this point, GFEs have to include all items or services that would be reasonably expected to be furnished in conjunction with the scheduled or requested item or service. So this includes what HHS refers to as the primary item or service, which could, for example, be an E&M visit or a procedure, but it also includes those items or services that are reasonably expected to be furnished in conjunction with that primary item or service. And that could be services provided by that same provider or even by separate providers and facilities. So that could, you can see some examples here, labs, anesthesia, facility fees. For PM&R, for example, a PM&R physician might schedule a service in a hospital outpatient department. And in that case, the hospital would likely be billing facility fees that would be charged to the patient. And so those facility fees would have to be included on the GFE. Another example might be when a PM&R physician treats a patient for carpal tunnel syndrome and knows that a custom splint will be needed following that treatment. So then the splint and the splint provider would also need to be included on that GFE. You know, it's worth noting, however, that if there are items and services that are expected to be separately scheduled, then those items or services, you know, basically information about those items and services and their expected costs do not need to be included on the GFE, although they might need to be included just kind of as an aside, which I'll go into in a little bit. I wanted to go to that notion of reasonably expected. It's, you know, it's very likely in many cases that providers can't always predict what services you might need to provide a patient. So as another PM&R example, if a patient goes in for knee pain, but then during the appointment, the patient also says they have a frozen shoulder, then it might make sense for the patient to also receive a shoulder injection during that same appointment. And that's fine, that injection can be provided, even if it wasn't on the GFE. And that's because when the patient scheduled the appointment that injection was not reasonably expected to be furnished based on the information that you had at the time. However, you know, I think the thing to remember here is that you want to have good medical record documentation detailing what the additional services were that were performed, clinical justification for why they were performed, and also information about why they couldn't have reasonably been expected to be furnished in advance. And that's because there's the potential for the patient to contest these additional charges. And that's that process, that patient-provider dispute resolution process, that Bob referenced that we'll be going into in more detail later. But their patient's ability basically to access that process really hinges on having this GFE provided. So that's really important. And then the last bullet here that I wanted to touch on is that GFEs do have to reflect the cash pay rate that providers are planning to bill patients, including any anticipated discounts or adjustments. And that's so that the patient really has a full understanding of the charges that they're going to be billed. Next slide, please. All right, so in line with the requirement that the GFE include information not only on the primary item or service, but also on other services that may be furnished by different providers, HHS has defined different roles that are involved in furnishing the GFE, and each role has its own separate set of responsibilities. So first, what we have is what HHS calls the convening provider or facility. And HHS defines that entity as the provider or facility who receives the initial request for GFE from the patient and who would be responsible for scheduling the primary item or service. So given the services that PM&R physicians furnish, I'd expect they largely serve in the role of the convening provider. There's also what HHS calls the co-provider or co-facility, and that's the provider or facility that is not the convening provider or facility, but that does furnish kind of those other services customarily provided in conjunction with the primary item or service. So again, that would go back to things like the lab providers, the anesthesia providers, the facilities. Those entities would be the co-providers or co-facilities that are implicated in this GFE requirement. Just so I don't get tripped up each time, I'm going to refer to convening providers and convening facilities instead of — sorry, convening providers instead of always saying convening provider and convening facility. And I'll just talk about co-providers instead of also saying co-provider and co-facility each time. All right, next slide, please. So those are the two distinct roles with their responsibilities, which I'll walk through here. The convening provider is responsible first for making that upfront determination about the patient's uninsured or self-pay status. They are then also responsible for contacting the applicable co-providers and requesting that those co-providers submit their information about expected charges for items or services that would be furnished with that primary item or service. One thing to note here is that the convening provider has to provide that information back to the — rather, the convening provider has to conduct the outreach to the co-provider within one business day of the GFE being requested or the service being scheduled. And then once all the charge data is collected from the co-providers and co-facilities, then the convening provider is an entity that would be responsible for consolidating all that information and providing that GFE to the patient. Likewise, if there are any changes to the GFE that might occur before the service, then the convening provider is also responsible for providing updated GFEs to the patients as well. For the responsibilities of the co-provider and co-facilities, once the co-provider receives a request from the convening provider, they're responsible for providing the requested information back to the convening provider within one business day. And then, likewise, if there are any changes in the scope of the submitted GFEs, or if it turns out that they can no longer provide the service and replacement providers are needed, they have to provide that information to the convening provider at least one business day before the scheduled service. The other thing to note is that patients can actually go directly to a co-provider and request information about the services that they would be providing and the charges associated with that. And in that case, the co-provider has to provide a GFE to the patient, basically kind of standing in the place of a convening provider or taking on the same responsibilities as the convening provider. All right. Slide three. Next slide, please. All right. So, as I mentioned in the previous slide, there could be times where information in the GFE has to be updated. So, that could be if there's a change in an expected charge or if a provider facility can no longer furnish the service. And in those cases where there are changes, again, the convening provider has to issue a new GFE at least one business day before the item or service is scheduled to be furnished. If those changes are not, if the provider is not aware of them or if they learn about these changes or if they take place less than one business day in advance, then the provider that required the change has to accept the GFE amounts already that have already been provided. And likewise, if there has to be a replacement provider, then that replacement provider has to accept the amounts on the GFE as well. If all of that takes place less than one business day before the scheduled service. And then separately, you know, we talked about the GFE having to be provided upon request or upon scheduling. So, if there is a GFE that's provided to the patient upon request without there being an actual service scheduled, but then the patient does later schedule a service, then the convening provider is responsible for providing a new GFE to the patient once that service is scheduled. All right. Next slide, please. All right. So, we've discussed some of the timelines that are in play, specifically that the provider, the convening provider has to request expected charges from co-providers within one business day and then the co-provider has to report expected charges back to the convening provider within a business day. Here, there are additional timelines that apply for actually getting the completed GFE to the patient. And you can see here that the timing depends, and it depends based on the date of the request relative to the date of the scheduled item or service. So, to start, if there is no scheduled date because the GFE is requested, but then no service has been scheduled, or if the scheduled date is more than 10 business days out, then the GFE has to be provided no later than three business days after scheduling or after the request. If the scheduled date is between three and nine business days out, then the GFE has to be provided no later than one business day after scheduling. And in cases where a service is scheduled or an item is scheduled less than three business days out, then there's, you know, like, then the requirement is that no GFE is required at that time, kind of, I think, in recognition of the fact that it takes time to pull all this information together and get information to the patient. So, I will note that these timeframes are set in statute. Next slide, please. All right. So, that's obviously a lot to accommodate in a short time frame, and especially if there are going to be several co-providers involved in furnishing services, it's just a lot to take on. However, we, you know, it's important to note that HHS does understand that there's a lot involved in that, a lot of challenges associated with collecting information from co-providers, you know, having mechanisms in place to exchange that information easily, preferably electronically, information about, you know, making sure that pricing is accurate. So, in light of all of these challenges, HHS kind of initially, when they initially announced these rules, they specified that they would be exercising enforcement discretion in cases where GFEs for these uninsured or self-paid patients don't include the expected charge information from co-providers. So, that was included. It was originally supposed to be enforcement discretion through 2022. However, HHS has, since that time, specified that they are going to continue that enforcement discretion and that they expect to undertake rulemaking around this particular requirement given all the challenges that they've heard from stakeholders. They have said that when they issue rulemaking, that the requirements around these co-provider charges on GFEs will be subject to a prospective applicability date. So, folks will have advanced warning on kind of when any new requirements regarding these co-provider charges will need to be included on GFEs. That being said, this enforcement discretion only applies in states where the federal government serves as the enforcement entity. However, there are many states where the states are primary enforcers, and so for those states, HHS has encouraged states to take a similar enforcement discretion approach while these challenges are being worked out and while HHS figures out what it wants to do through rulemaking. So, you may want to check to understand whether enforcement of these provisions is being conducted by the state or the federal government, and if it's a state, what your state's policy is. All right, next slide, please. All right, so content requirements. The GFEs have content requirements that are separate but largely similar when it comes to the GFEs that convening providers have to furnish to patients as well as the GFEs that co-providers have to furnish to the convening providers. There are a few points where these requirements in the content diverge, so I'll walk through them pretty quickly. First, the GFEs have to include the patient's name and date of birth, so that's pretty straightforward. Next, we have a description of the primary item or service that's being furnished, and if there's a date that the service is scheduled, that date has to be included as well, and this is a requirement that only applies to the convening provider, not the co-provider. In addition to that primary item or service, the GFE also has to include an itemized list of all other items or services that are grouped together by the specific provider facility furnishing those services, and so that's like information for the convening provider as well as information for each additional co-provider. Then, moving on, the GFE also has to include information about diagnosis codes, service codes, and expected charges, also has to include information that's specific to each provider, so for each provider, the name, the NPI, the tax identification number, location, et cetera, and then I kind of talked about this a little bit, but there are services that may be kind of affiliated or associated with a primary item or service that would need to be separately scheduled, so those items and services don't have to, you know, you don't have to provide the full gamut of information as far as those specific diagnosis codes and CPT codes and charges, but there is, there does need to be information that these additional services may need to be furnished separately and scheduled separately, and so a list of these services have to be included on the GFE, and there are some associated disclaimers there, and then finally, there are additional disclaimers that HHS specifies need to be included, and those vary based on whether it's the convening provider or the co-provider, so those are, those could be things like the fact that the GFE isn't a contract and the fact that patients have a right to the patient provider dispute resolution process. You can see a full list of the disclaimers in the model notice that's linked there, and I will note that CMS has made that model notice available just as a resource, but it's not mandatory that you use that particular one. Next slide, please. Next slide, okay, so here I'm just walking you through some of the main components of the model GFE so that it's a little bit easier to visualize. You can see on the left side, the first page, the patient information that's required at the top, and further down, you see the primary item or service along with information, along with space, rather, to provide information about diagnoses and about the date of service, if that's applicable. On the next page, you have a summary of costs by provider and the total estimated costs for the patient. Next slide, please. Next slide, please. On the third page, you start seeing detailed information for each provider, including all that provider-specific information, name, location, NPI, TIN, and then space to provide detailed information about those services that are being furnished, along with a total at the bottom for that provider. And, of course, additional sheets can be provided for each separate provider or facility that's expected to provide services. And then, the page on the right, the last page that I'm showing here, includes space for that list of services that are expected to be needed, but that would be separately scheduled and, therefore, are not, you know, more detailed on this particular GFE. I didn't include all of the disclaimers, just because they're very wordy and they're a lot to go through, but definitely take a look at them in the model link. Next slide, please. Now, just a few notes about formatting requirements. GFEs have to be provided in written form, either on paper or electronically, if that's what the patient requests. If they are furnished electronically, then they have to be able to be saved and printed. And, additionally, HHS has specified that these GFEs have to be provided in a clear and understandable language, as well as in accessible formats and languages spoken by the individual, if necessary. Next slide, please. So, in addition to having to furnish the GFEs themselves to uninsured or self-pay patients, convenient providers also have to provide a notice to patients that the GFEs are even available. So, you know, they have to say that patients have the right to the GFEs. This notice has to be written in a clear and understandable manner. Again, it must be prominently displayed on the provider's website and also easily searchable. It also has to be displayed in the office and on-site, wherever questions about costs or scheduling might occur. Providers are also required to provide information about the availability of GFEs orally to patients when scheduling an item or service or when questions about costs arise. And, in fact, HHS has indicated that if there's any, if the patient even brings up a question about the potential cost of a service, then that should or must be considered a de facto request for a GFE from the patient to the provider, and therefore the GFE has to be provided. As with the GFEs themselves, the notice also has to be made in accessible formats and in the languages spoken by individuals. And here I've also included a link to a model notice. Next slide, please. And then just quickly regarding retention requirements, providers and facilities are required to maintain the GFE as part of the medical record and to make that GFE available to the patient for at least six years. Next slide, please. All right. And finally, before I move on to the patient-provider dispute resolution process, I wanted to highlight a couple of special cases where there are some adjustments to the GFE that HHS has said are permissible in order to reduce burden or to reduce confusion. So the first special case that I'm going to just touch on here is when there are multiple recurring items or services that need to be scheduled. So, for example, there might be a case where a PMR physician schedules a patient to come in for repeated acupuncture treatments over the course of a couple of months. In this case or in cases like these, rather than requiring the provider to furnish a new GFE each time the service is furnished, providers can issue a single GFE for that recurring service. But certain conditions do have to be met. So the GFE has to clearly state the scope of the service that's recurring. That would include things like the time frame over which the services will be furnished, the frequency, and the total number of recurring items or services. And then additionally, HHS has specified that a single GFE can only be used for these recurring services up to a period of 12 months. So if the service continues to recur beyond 12 months, then a new GFE would have to be provided for that next 12-month period. Next slide. All right. And the other special case I wanted to highlight here is where a convening provider has no intent to bill their uninsured or self-pay patient. And in this case, HHS understands that providing a detailed GFE might not make sense, would be more burdensome, especially if there's no intent to cover. So they've specified that the convening provider can furnish an abbreviated GFE and still be considered compliant with the GFE requirements as long as they don't bill the patient and there are no items or services that are expected to be furnished by co-providers or co-facilities. These providers also have to kind of adhere to other requirements that apply. So for example, around the timelines for providing GFEs. And HHS has really made clear that this is an alternative that they wanted to provide in cases like this in order to reduce burden for those practices that are planning to furnish these free services. But at the same time, they also wanted to make sure that there was documentation in place that the patients could use and rely on if, you know, they do end up getting billed and want to submit a dispute to the patient provider dispute resolution process. And in fact, you know, these items and services could still be potentially subject to that process if patients are billed more than $400 after being told that they were not going to be billed at all. Next slide, please. And I'll get back to that $400 amount in just a bit. So as far as content of the abbreviated GFE, lots of the same elements that were required before, including the name and date of birth, all of that provider specific information, and the scheduled date of service if that date is available. However, instead of listing the specific services and codes, the abbreviated GFE can just include a statement saying that the provider or facility will not bill the individual for any items or services furnished on that date, or if there's no date that the provider will not bill the individual for any items or services period. And that does leave things a little open-ended. So, you know, if that service is, if that GFE is requested, and then a service is scheduled, I think, you know, a good practice would be to actually, and actually you're required once it's scheduled to furnish a new GFE that includes the date so that it's clear that for that specific date of service, no charges would be billed. And of course, applicable disclaimers. Next slide, please. I also included a link, but next slide. And here you can see what that model looks like. I think that the key thing here is the bolded statement at the top indicating that the patient won't be billed for services. And I think the other notable difference is just, you know, the length and complexity of this abbreviated GFE versus the standard GFE. Obviously, with less information to fill out, you would expect that there would be significantly lower burden. All right, next slide, please. All right, so now we're going to go on to the patient provider dispute resolution process, or PPDR. And this is a process that's available to uninsured or self-paid patients after they've received services that were included on the GFE that they've been provided. At a high level, the NFA, the No Surprises Act provides for this PPDR process when they receive services that were included on the GFE, but then the actual charges are substantially in excess of the amounts on the GFE. And here, you know, I put substantially in excess in quotes because that's the language that's specified in statute. HHS currently defines substantially in excess as an amount of total billed charges that's at least $400 or more than the total amount of the expected charges that were included on the GFE. So that's that $400 that I mentioned earlier. And that $400 comparison from the GFE to the actual billed charges applies at the provider level for each unique provider facility listed on the GFE. It also includes services or items that weren't included on the GFE. So even if a service wasn't on that GFE, the total billed items, or the total billed charges for those services would still count towards the $400 threshold. I'll also just flag that that $400 amount has been set by HHS using its administrative authority. So HHS has the option of changing this amount going forward through future rulemaking. Next slide, please. On this slide, I provided a couple of illustrative examples of how this might play out. So in the first table at the top, we see that there are two providers, the convening provider, of course, and the co-provider. While the co-provider, you know, billed charges that were consistent with the amount on the GFE, the convening provider's charges, as you can see, are $600 higher. Now, that could be because there was higher pricing for the same service that was initially quoted on the GFE, or the provider might have realized that an additional service that was not included on the GFE had to be furnished on the same date unexpectedly, leading to those increase in charges. Regardless of what the reason is, the total charges are more, did go up by more than $400. And as a result, the charges for the convening provider could be subject to that PPDR process. In the second table, again, you have these two providers. Here you have total cumulative charges for both providers going up by $500, but the charges for each provider only went up by $250. And so since the increase in charges for neither provider meet that $400 threshold, then neither provider's charges would be subject to the PPDR. Next slide, please. All right, so here are some of the requirements for initiating that dispute. First, the dispute has to be submitted by the uninsured or self-paid patient or their authorized representatives. However, HHS has said that the authorized representatives can't be affiliated with any of the providers on the GFE. Second, the dispute has to be submitted within 120 calendar days of receiving the initial bill. Third, the submitters are encouraged to submit disputes through the Federal Independent Dispute Resolution portal or IDR portal, and I've provided a link here. However, HHS has said that they'll also accept disputes through electronic email or, you know, paper mail submissions. Fourth, as part of their submission, submitters have to include some specific information about the items and services under dispute. They also have to provide a copy of the bill and a copy of the GFE, among other things, that are included as part of the submission. And then lastly, there is an administrative fee that the submitters are required to submit. HHS has currently set that fee at $25 for 2023, but again, this is a number that's subject to HHS's discretion and potential future change. And I will note for that administrative fee, while that is paid initially upfront by the submitter, ultimately the party that does not prevail in the dispute will be responsible for bearing the cost of that fee. Next slide, please. So, if a provider receives notification that his or her or their bills are being disputed through this PPDR process, then several rules apply that I've kind of outlined here. First, those bills cannot be moved into collections, and the provider cannot threaten to move those bills until this whole process has concluded. Likewise, the provider is prohibited from threatening the patient or taking any other retributive action. The provider is also then responsible upon request for submitting information to the entity that is going to be handling the dispute, and that entity is called the Selected Dispute Resolution, or SDR, entity. And so, you know, I've outlined a few things here that need to be submitted, including a copy of the GFE, a copy of the bill charges. I think that the key thing here, potentially most importantly, is the documentation that's needed to justify the increase in charges between the GFE and the bill, and there are two main considerations here. The first is that the increase reflects the cost of medically necessary items or services, and second, that the increase is based on unforeseen circumstances that could not reasonably have been anticipated by the provider or facility when the GFE was provided. And to the latter, just a reminder that the GFE is supposed to reflect the cost of all items and services that are reasonably expected to be furnished to the patient in conjunction with that primary item or service. So, you know, if the service was based on unforeseen circumstances and the documentation supports that unforeseen nature, then the dispute could potentially be determined in the provider's favor. But again, as I mentioned before, just underscores the need for good documentation of what the additional service was, why it was medically necessary, and why it could not reasonably have been anticipated at the time the GFE was furnished. Next slide, please. All right. So, you know, once that dispute is initiated, there is still the possibility that the dispute can be resolved via settlement between the patient and provider before the SDRE or the Selected Dispute Resolution Entity makes a payment determination. And if that's the case, then the provider is responsible for notifying that SDR entity through the federal IDR portal no later than three business days after the date that the agreement was reached. Additionally, in this case, both parties would be responsible for paying half of the administrative fee. So, at this point, $12.50 each. And then HHS does make a point of noting that just because a patient makes a partial or even a full payment of bill charges, that does not mean that a settlement has been reached. So, providers really need to be careful not to make that assumption. Next slide, please. But if the settlement is not reached independently between the parties and the determination is left to the SDR entity, then that entity is responsible for finalizing a determination within 30 days. The entity has to presume that the GFE reflects the appropriate amount unless, you know, the information submitted by the provider provides that adequate justification, both about the medical necessity and the enforcing nature. And if the justification isn't sufficient, then the GFE expected charges would prevail. And the payment amount that the patient would be responsible for paying is equal to the amount on the GFE. Or if there was a service that was not on the GFE for that particular service, the payment amount would be zero. If the justification that the provider submits is sufficient, then the SDR entity is responsible for determining what the right payment amount would be. And generally, they have to choose either the lesser of either first the bill charge or a median payment amount that's reflected in an independent database. All right. Next slide, please. And then just quickly, when the SDR entity is making its payment determinations, they're going to be looking at each unique bill service, so seeing whether the justification applies and is sufficient for each unique bill item or service, and then they'll make a payment determination for each service separately and then add those services up together to reach a total payment amount across all of the services. If the patient who initiated the dispute prevails, the SDR entity would also reduce the total amount of the amount owed by the patient by the administrative fees such that the provider is ultimately responsible for paying that fee. And I will also note that once that determination is made, except in certain cases that might involve fraud, then that determination is generally binding, except that patients and providers do still have the option of continuing to agree to further changes. So the patient might offer to pay more or the provider might agree to accept less or provide a discount or both. So that option still remains. All right. Next slide, please. And then lastly, I'll note that in some cases, states have their own PPDR process. PPDR processes do have to provide at least the same level of consumer protection as the federal process, so HHS has undertaken a review of state processes and made a determination for each state, and you can find information about those state-specific assessments at the links provided. All right. Next slide, please. All right. So just ending with a few quick key takeaways. Next slide. First, convening providers are required to provide that GFE if the patient is uninsured or self-pay. Next, the GFEs have to include information for all items and services associated or in conjunction with that primary item or service, including information for co-providers and facilities. But of course, as I mentioned, HHS has announced enforcement discretion regarding the inclusion of that information about the co-facility's expected charges pending future rulemaking. Next, if the bill charges are at least $400 or more, higher than the actual charges that were or higher than the expected charges that were included on the GFE, then the uninsured or self-pay patient can initiate and submit a dispute to the PPDR process. And lastly, the key takeaway, the last key takeaway here is that the enforcement of these requirements will vary by state, so providers should understand whether these requirements are subject to federal or state enforcement. All right. Next slide, please. And then lastly, before we wrap up, just wanted to circle back. I think Bob alluded to this, that I would go back to the GFE requirements for insured patients. Under this requirement, providers would be required to send GFEs to health plans or issuers for services provided to these insured patients, and that GFE would, I think as Bob described, would be for the purpose of enabling those plans and issuers to provide advanced explanations of benefits to their members. Of course, we can expect that this requirement would be significantly more burdensome for physician practices than the GFE requirements for uninsured and self-pay patients that I've just been discussing, just given the volume of patients that would be affected. So this would be, you know, almost all patients that don't have, you know, that have insurance coverage, but not through federal programs. But unfortunately, you know, as Bob mentioned, there is not yet rulemaking here, and a lot of questions remain. And so, you know, I just provided a few examples of questions that, you know, we're still mulling over and wondering about, you know, when the first question is, when would these rules even be promulgated, and when would the requirements be implemented? It's already been more than two years since they should have been issued. Will the GFE requirements mirror what's in place for the uninsured and self-pay GFEs? How will this new GFE requirement, and the fact that it has to be sent to insurance companies, change workflows and processes? And how will these concepts about the co-providers and co-facilities be incorporated into these GFE requirements at all, if at all? So all of these are questions that are still outstanding, and I'm sure there are tons of others that we won't know the answers to until HHS issues these rules. At the same time, we do understand that HHS is kind of grappling with these challenges and implementing the challenges of implementing these requirements. And so we are hoping that they are taking a thoughtful approach and taking this time to develop an approach that will be as minimally burdensome as possible. And this is something that AAPMNR is tracking, and we'll keep members apprised of after more information becomes available through rulemaking. All right, next slide, please. Here I just provided a few additional resources on the things that I've discussed. Next slide. And with that, I'll stop for questions. I know we just have a few minutes left. Yep, there's only a few minutes. I've been looking at the questions. There haven't, there's only really been one. So if you do have any questions, please drop them in the Q&A box on your screen, and we'll try and answer them. During your presentation, before you got to the photos of the model GFE, there was a question about whether we had samples. And so I sent the link to the attendee who asked that question, although I don't think that everybody can see that. But all of those links will be in the presentation for you to copy afterwards. It looks like there is another question that just came up about the elimination of hospital based clinic payments. If you have a little more info on that, feel free to type it into the chat. But I think what this might be referring to is the effort by members of the public to by Medicare to eliminate the difference between basically the payment difference between office visits in a physician's office and the enhanced payment that a clinic visit will get because it's designated as a hospital facility. There's a lot of activity around that that's happening right now. And so I don't know where that's going to land. Congress is considering whether to address that. And that's something that could eventually happen for other services. Right now, the agency already has a policy to try to pay hospitals for clinic visits at a rate that is comparable to a fee schedule office visit. But they have statutory limitations on that. So they can't apply it to services beyond the hospital clinic visit. And so people are looking at trying to look at ways to equalize payments between settings to disincentivize perhaps paying for the same thing more in different settings. Regarding the GFEs, Cindy, maybe here in the last minute, unless other questions pop up, we can talk just a little bit more to about just this state versus federal component, because I do think that it is important to getting questions answered. So I thought maybe we would just spend a second here talking about that. And one of the slides that Cindy put up was the was a link to the state, the letters that the federal agency has put out for each state. And if you go and you look for your state in that, there are basically three different sections to that letter. And so just to orient you to what those sections are, there are really three different areas in this whole No Surprises Act terrain where there's state versus federal issues. The first one is basically does the state have a law that already addresses the surprise billing proper stuff that I spoke about at the very beginning. So that talks about whether there's a state law for that. Then there's also the piece about enforcement, which Cindy had mentioned. So it's possible that a state doesn't have a law that speaks to the surprise billing. The state doesn't have its own PPDR system. The state is going to be the enforcement entity over these rules. So you want to make sure that you figure out who the enforcement entity is per what Cindy had mentioned before. And then the last thing is that's where it also outlines whether the state already has a PPDR process that would govern the situations that we've discussed today. Cindy, did you have anything else that you wanted to add to that? I just feel like it's a key piece to understanding all this. Just that on that slide, there were two links. One was a link to those detailed state-by-state assessments. And the other was kind of a more easy to understand graphic. And I do apologize. I kind of rushed through this because I wanted to make sure we got to the end and left time for questions. But the graphic, you can use that graphic to kind of see at a high level who's responsible for enforcement, whether there are laws that are in place. And there are nice dropdown menus that you can use to select and figure out what's going on in your state. So just a quick, easy reference that's there as well. Thanks. And then the last thing, and then I'll turn it back over to you, Megan, is that I'll just mention, Cindy mentioned the model forms that are available. Just so you're aware, the terminology that the agency uses for whether you're required or whether it's just a model form that will help you meet your obligations. So model is sort of suggested. And if you use it, it checks all the boxes of what's required for these disclosures. In other instances, when the agencies require the use of an exact form, they'll call it their standard form. So if you're ever looking through all these materials, you'll notice that the difference, the nice thing about the model forms is that they're kind of pre-approved to be compliant with the requirements if you fully complete them. But if you've already been providing GFEs and using something else that still meets all of the obligations that Cindy walked through to be compliant, then you can go ahead and use those. So with that, we'll wrap up. We're right at the top of the hour. And Megan, I'll turn it back over to you.

No Surprises Act

Good Faith Estimate

uninsured patients

self-pay patients

balanced billing protections

patient-provider dispute resolution

co-providers

co-facilities

Selected Dispute Resolution Entity