Congress passed the No Surprises Act to protect patients from surprise billing from health care providers. Some parts of the Act became effective on January 1, 2022. Health care lawyer Susan Freed is answering frequently asked questions on how providers should proceed.

In 2020, Congress passed the No Surprises Act (NSA) in an attempt to protect uninsured patients from surprise billing. Some sections of the NSA became effective on January 1, 2022, while other sections are on hold until regulations are released. 

This article covers the GFE dispute resolution.

No Surprises Act and Good Faith Estimates - Dispute Resolution

What happens if the actual charges of the services vary from the charges included in the GFE?

If actual charges vary, in total by $400 or more, from the charges in the GFE, the patient may initiate the dispute resolution process.

Is the $400 threshold a combined total for all providers included within the GFE or per provider?

The $400 applies to all services and all providers within the GFE.  The aggregate charge cannot exceed the total in the GFE by $400 or more. For example, if the patient schedules a colonoscopy, and the items and services included in the GFE are the facility fee, the gastroenterologist, the anesthesia provider, and the laboratory, the combined total of actual charges for all cannot be $400 or more than what was included in the GFE.

If the actual charge for all items/services is $400 or more than the total in the GFE, and the GFE includes multiple providers, who is ultimately responsible if the patient initiates the dispute resolution process?

All of the providers included in the GFE would be subject to the dispute resolution process and the certified IDR entity will ultimately determine which provider(s) are responsible, if any, for any overage. The determination will be made upon the facts and circumstances, including the reasonableness of the items/services included within the GFE.

When providing the expected charges in the GFE, do we include potential charity care or other discounts the patient may be eligible for?

Yes, providers are required to include any discounts or other assistance the patient is eligible for, including time of service payment discounts and charity care or other financial assistance.

Anesthesia billing is often based on the procedure time which is not always known at the time of scheduling. How is this addressed in the regulations?

Unfortunately, this and many other issues are not addressed in the interim final regulations. The GFE is required to be based on “reasonable expectations” at the time the item/service is scheduled. Anesthesia providers should work with surgeons and facilities where they perform services to come up with reasonable expectations for surgeries and procedures and should consider including in the GFE how charges are determined, such as the incremental cost.

How does a patient utilize the dispute resolution process?

Self-pay and uninsured patients can initiate the dispute resolution process by submitting a notice to HHS through the online federal IDR portal, submitting an initiation notice electronically, or submitting through the mail if postmarked within 120 calendar days of receiving the initial bill containing the charges in dispute. Patients must include specific information in their initiation notice, including the date of service, a description of the service, a copy of the bill, the last four digits of the account number on the bill, a copy of the good faith estimate, contact information for the providers involved, and the uninsured or self-pay patient, and the state where the services were furnished.  Patients must also pay a $25 administrative fee which may ultimately be assessed to the provider if the patient prevails.  If the information submitted by the patient is determined to be incomplete, the patient will be notified and given 21 days to provide the required information.

How will a provider be notified of the patient provider dispute resolution (“PPDR”) process?

Once it is confirmed the patient is eligible to utilize the PPDR process, providers will be notified either through the federal IDR portal, or via electronic or paper notice that the PPDR process has been initiated by a patient and request the provider provide specific information within 10 business days after receipt of the notice, including a copy of the good faith estimate, billed charges and documentation providing evidence to demonstrate the basis for the difference between billed and expected charges. This is the provider’s opportunity to explain why the original good faith estimate was a reasonable estimate and to justify why the costs varied significantly between the good faith estimate and the billed charges. The selected dispute resolution (“SDR”) entity then reviews the information and notifies the patient and provider of its decision within 30 business days.

The provider’s first notice of the PPDR process will come from the SDR entity and should have an assigned PPDR case reference number as well as the information required to be submitted by the provider  Because of the relatively short window to respond, providers will want to ensure their employees understand who they should route SDR notices to.

Are providers allowed to continue collection efforts during the PPDR process?

Providers are not allowed to move a bill into collections or threaten to do so during the PPDR process and must pause collections if the bill has already been moved to collections. Provider may also not bill or collect late fees on unpaid amounts and must refrain from any retaliatory actions against the patient for initiating the PPDR process.

Health care providers who would like to submit a question for inclusion in a future FAQ installment should email susan.freed@dentons.com