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Surprise Billing Part 2 and Patient Estimates

On January 1, 2022, the second major section of the No Surprises Act is set to take effect. The comment period for the proposed regulations ended on December 6th and now we await any changes to those regulations before the go-live date. One of the many items covered in phase two, are the regulations around the convening provider’s requirement to provide good faith cost estimates, to uninsured and self-pay patients for scheduled services.

When scheduling a patient for a service or item, a convening provider must inquire regarding the patient’s intent to submit the service or item to a Health Insurance Plan for coverage. If the patient is uninsured, or insured but wishing to not submit the service, the provider must provide the patient a good faith estimates of all the services/items to be provided.

The good faith estimate must include expected charges for the items or services that are reasonably expected to be provided together with the primary item or service, including items or services that may be provided by other providers and facilities. If an item or service is something that isn’t scheduled separately, it will generally be included in the good faith estimate. For example, a scheduled surgery estimate would include, facility fees, physician fees, anesthesia fees, radiology fees, labs, etc. done at the time of the surgery service. Pre-surgery visits, and post-surgery therapy visits, will not be included in the investment.

The intent of the law is for patients to have a full understanding of the economic impact of receiving medical care, in essence to have “no surprises.” However, a lack of understanding of the billing system, has created an enormous burden on the Hospitals, by defining them as convening providers, and making them responsible for organizing multiple providers charges.

HHS has recognized the difficulty in the Hospital providing all these services in one estimate. Therefore, they have stated that they year 2022, will be viewed with discretion, as providers adapt to these new scenarios. The regulations also place requirements around the co-providers to promptly provide the requested information to the convening or main provider.

Join Altum Healthcare’s CEO, Elizabeth Richards, Esq., as she discusses this new frontier in patient estimates at the Georgia AAHAM, HFMA & GAMA Holiday Education event on December 15, 2021, or email for a copy of the presentation and/or to book her for your event or staff.

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