Basics of Good Faith Estimates
Starting on January 1, 2022, the No Surprises Act (NSA) protects uninsured or self-pay individuals from many unexpectedly high medical bills. The Good Faith Estimate shows the costs of items and services that are reasonably expected for patients’ health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. Patients could be charged more if complications or special circumstances occur. If this happens, federal law allows patients to dispute (appeal) the bill.
The Act requires that health care providers and facilities give uninsured (or self-pay) individuals an estimate for the cost of their health care before the individual agrees to get the item or service. To receive a good faith estimate, patient must schedule an item or service least 3 business days prior visit date. In such cases, providers must submit good faith estimates no later than 1 business day after scheduling. If patient schedule the item or service at least 10 business days before, or request cost information about an item or service, the provider or facility must give a good faith estimate no later than 3 business days after scheduling or requesting.
If patients have questions about the cost of items or services, the provider or facility must inform patients in writing or orally about requesting a good faith estimate. Patients will find information about good faith estimates on provider or facility’s website and in the provider or facility’s office or on-site. Note that the good faith estimate is not a bill. The good faith estimate shows the costs of items and services that provider or facility expects to charge for an item or service. The estimate should be based on information known at the time the estimate was created and does not include any unknown or unexpected costs that may arise during the course of treatment. For example, an individual could be charged more if complications or special circumstances occur. The good faith estimate includes a list of items and services, grouped by each provider or facility, that includes:
- Applicable diagnosis codes,
- Expected service codes,
- Expected charges associated with each listed item or service for the primary provider or facility (the main provider or facility you are scheduling with), and
- Any expected charges associated with each listed item or service for the co-providers or co-facilities (the other providers or facilities who will also be a part of your care and bill you separately).
Note that for the year 2022, the good faith estimate may not include all expected charges for items and services from a co-provider or co-facility for items and services that are usually expected to be provided along with the primary item(s) or service(s). This means, for example, that until January 1, 2023, if a patient schedules a knee replacement surgery with a particular surgeon, then surgeon’s good faith estimate may not include the expected charges from your anesthesiologist. However, Patients can request a good faith estimate directly from a co-provider or co-facility.
Patient-Provider Dispute Resolution (PPDR)
If the uninsured or self-pay individual is billed for an amount at least $400 above the estimate, the individual may be eligible to start a Patient-Provider Dispute Resolution (PPDR) process by submitting a request to U.S. Department of Health and Human Services (HHS) and paying a small administrative fee (i.e., $25). The PPDR process is handled by a third-party company certified by the HHS. This company will decide if the estimated amount, or billed amount, or another amount in between the estimated amount and billed amount should be paid. This document contains specific requirements and information about the ‘Good Faith Estimate’ and PPDR process.
We shared selective information about ‘Good Faith Estimates’ for reference purpose only, for detailed information, you can refer to CMS document on ‘Good Faith Estimate and the Patient-Provider Dispute Resolution (PPDR)’.