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No Surprises Act

Policy, Forms, & Training

Continuing Education Credits: 2

This course is available for purchase

$199

This course is designed to provide the practicing chiropractic physician with an approach to comply with the No Surprises Act through two video training modules and office forms to implement appropriate practice procedures. The course will allow the practice to provide uninsured/self-pay patients with a good faith estimate and understand the notification and consent requirements of 45 CFR 149.610(b)(1)(iii).

Length: Approximately 100 minutes.

This course is worth 2 chiropractic/chiropractic assistant CEU in states that accept PACE and distance learning. Click here to view PACE states. If your state says ‘Search the PACE Catalog’ after it, the course is approved.

Presenter

Scott D. Munsterman, DC FICC CPCO

The “No Surprises Act” requires that patient cost-sharing, such as copayments, co-insurance, or a deductible cannot be higher than if such services were provided by an in-network provider, and any cost-sharing obligation must be based on in-network provider rates. This act prohibits out-of-network charges for items or services provided by an out-of-network provider at an in-network facility, unless providers and facilities provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill the patient more than in-network cost-sharing rates. This Act also addresses providing a Good Faith Estimate through notice and consent to patients considered uninsured or self-pay.

No Surprises Act FAQs

In personal injury, you may have to refer a patient out to specialists; however, you won’t know generally until later. Yes, you often have imaging (MRI, xRay), and often there is a pain management MD referral. Of course, you have no idea if one imaging or a number of images will be needed often, and certainly you don’t know what the pain MD is going to recommend. So how do you address the good faith estimate at the beginning for these situations? What must you include?

PI and WCP are not included in the list of payers under this act - however, as you probably heard me say, that if you suspect a patient will be self-pay, then I would provide a GFE at that time. In regards to addressing it, again it wouldn't happen at the beginning of care for these cases in my opinion, but rather only at a time it becomes apparent the patient is in a self pay situation.

Just to clarify, the good faith estimate is not used for patients that have insurance that covers the services not dependent if we are in or out of network?

Correct - but it does cover the items/services not covered by their plan

If we have a patient that doesn't have insurance coverage for chiropractic and we send them to get x-rays at a facility that they do have coverage for, do I have to put that fee on my good faith estimate?

Yes

What do we have to have posted in two places in the office? Good Faith Estimate available on request?

The Notice of Good Faith Estimate must be posted in two prominent locations in the office as well as on your website (if you have one).

Can you share examples of the forms you discussed on the webinar?

Here are links to forms provided by CMS:

Model Notice Consent Templates

Model notices and information collection
requirements for the good faith estimate
and patient provider payment dispute
resolution

You can access forms we have developed for you by purchasing our No Surprises Act Policy & Training course here: https://chiroarmor.com/no-surprises-act

Do we have to send good faith estimates to a self-pay or uninsured patient even if the charge is a zero amount. For example, a patient is on a financial assistant program or has a sliding fee scale discount based on income.

The law currently doesn't speak to any minimum amounts so the answer is yes.

On the template the CMS provided and in the info that I have seen, we are to include the patient DX on the estimate. If the patient is new to the office this information would not be known yet. Do I do a GFE for the patient's first visit and list it as TBD? And then do a second GFE once they have a treatment plan?

As recommended in our webinar, you would be providing an oral GFE (which is an estimated range of costs) and then when the patient arrives you will provide them with the written GFE with this same range. In the event information is not yet known (i.e., diagnosis) then enter TBD (to be determined).

Our office has a financial policy and insurance verification form that I have always used, and I do an estimate (for every patient) showing the initial visit and their visits for treatment. So, they have an estimate of all the cost ahead of beginning care. Wanting to clarify that I would need to do a separate GFE after the initial visit is done (even though most patients want an estimate for care as well) for the treatment plan with the DXs. Or can I add the Dx's after that is determined?

Yes, a GFE would need to be done for the treatment plan and for the total amount. In the event information is not yet known (i.e., diagnosis) then enter TBD (to be determined).

Does the Good Faith Estimate need to be a max of one page double sided? (The examples are multiple pages)

You can construct your GFE but make sure you include all elements per the regulation.

If it is one page max, and we send it electronically it will be two pages. Is that ok?

It can be provided electronically per the patient’s request and it must be able to be saved and printed by the patient.

How do we prove that the patient received the Good Faith Estimate and that we sent it in the time frame that is stated? Such as if the appointment in scheduled four business days in advance, I have to send the GFE within one business day.

We recommend this GFE consent form be signed by the patient, keep one copy for your records.

The Good Faith Estimate cannot be over $400, so if we are under is that fine?

Yes

I know you told me that we didn't need a GFE if they have insurance, but we do if it is not a covered service. So if we are in network and they are allowed 12 visits/year, do we need a GFE once they reach their visit limit?

Yes, if they decide to not file a claim.

Is a personal injury patient considered a self-pay patient requiring a GFE or are they an insured patient with no GFE required using their available medpay policy?

Personal injury is not covered under this act. But if the patient’s benefits run out and they become uninsured or self-pay, then the rules apply.

If an auto injury patient comes in stating they are covered under a 3rd party automobile insurance claim, which then becomes untrue for a variety of reasons, would we then provide a GFE at the time we become aware that they are no longer covered under that insurance, or do we only need to provide the GFE at that time if we are within the 120 days of the initial service?

You provide GFE once you identify a patient is uninsured or self-pay.

What do we need to post in two dominant places in the clinic? the price of all of our services? Everyone's plans would be different, so we would have to post prices for our services if I am reading this correctly?

The notice as provided by HHS.

What do we post on the website? Same questions as above? I followed the link for the templates and there were 7-8 documents with lengthy amounts of pages and it was difficult to decipher what we are supposed to use.

The notice as provided by HHS.

What do we need to do to implement with our existing patients? Do we need to have everyone sign something at this stage in their plans or wellness care?

The act applies to all patient who are uninsured or self-pay.

With Medicare patients does the ABN suffice, or do we need an additional document to have them sign?

The act applies to Medicare patients who are provided non-covered items or services and if they chose Option #2 on the ABN – which means they don’t want their claim filed with Medicare.

Kind of a general question to clarify... so we need to post general notices about the patients' rights in a couple places in the clinic, is that correct? And then the specific-to-the-patient Good Faith Estimate form would be filled out by us, given to the patient to sign, and then we would keep a copy on file and send the original home with the patient, is that overall correct? Additionally, since the law text includes this requirement for "items" as well as services, would that come in to play for items that we sell in the chiro clinic that I work at... non-DME retail items that we don't bill to insurance, such as vitamins/supplements, pillows, etc?

Yes to all questions.

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