Surprise billing & protecting consumers
Starting January 1, 2022, consumers will have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Through new rules aimed to protect consumers, excessive out-of-pocket costs will be restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network.
Currently, if consumers have health coverage and get care from an out-of-network provider, their health plan usually won’t cover the entire out-of-network cost. This could leave them with higher costs than if they’d been seen by an in-network provider. This is especially common in an emergency situation, where consumers might not be able to choose the provider. Even if a consumer goes to an in-network hospital, they might get care from out-of-network providers at that facility.
In many cases, today the out-of-network provider can bill consumers for the difference between the charges the provider bills, and the amount paid by the consumer’s health plan. This is known as balance billing. An unexpected balance bill is called a surprise bill.
The Consolidated Appropriations Act of 2021 was enacted on December 27, 2020 and contains many provisions to help protect consumers from surprise bills starting in 2022, including the No Surprises Act under title I and Transparency under title II. Learn more about protections for consumers, understanding costs in advance to avoid surprise bills, and what happens when payment disagreements arise after receiving medical care.
Good Faith Estimate/Understanding costs in advance
Getting cost estimates before you get an item or service if you’re uninsured or self-pay
Beginning January 1, 2022, if you’re uninsured or you pay for health care bills yourself (don’t have your claims submitted to your health plan), health care providers and facilities must provide you with an estimate of expected charges before you get an item or service. This is called a “good faith estimate.” Providers and facilities must provide you with a good faith estimate if you request one, or after you’ve scheduled an item or service. It should include expected charges for the primary item or service you’re getting, and any other items or services that are provided as part of the same scheduled experience.
The provider or facility you contact for a good faith estimate must provide a list of all items and services associated with your care. In 2022, the estimate isn’t required to include items and services provided to you by another provider or facility, but you can also ask these providers or facilities for a separate good faith estimate. In 2023, the provider or facility you contact will be required to provide co-provider or co-facility cost information.
For example, if you’re getting surgery, the good faith estimate could include the cost of the surgery, any lab services or tests, and the anesthesia used during the operation. But, in some instances, items or services related to the surgery that are scheduled separately, like pre-surgery appointments or physical therapy in the weeks after the surgery, might not be included in the good faith estimate.
Providers and facilities must:
- Provide the good faith estimate before an item or service is scheduled, within certain timeframes.
- Offer an itemized list of each item or service, grouped by the provider or facility offering care. Each item or service has to have specific details, like the health care code assigned to it and the expected charge.
- Explain the good faith estimate to you over the phone or in-person if you request it, and then follow up with a written (paper or electronic) estimate.
- Provide the good faith estimate in a way that’s accessible to you.
Once you receive a good faith estimate from your provider or facility, be sure to keep it in a safe place so you can compare it to any bills you get later. View an example of what a good faith estimate (PDF) may include . If you’ve had your service and find that the billed amount is at least $400 above the good faith estimate, you may be eligible to start a patient-provider dispute resolution process. Learn more about the dispute resolution process, including eligibility requirements and what information or documents you need to start a dispute.
The above information was taken from www.cms.gov/nosurprise.The No Surprise Act Official Form
A Modified Good Faith Estimate for DBK Wellness, LLC can be found here: GFE