Providers Are Calling For More Time To Implement Estimate Requirement In Surprise Bill Rule

Providers have a little more than six months to find a way to deliver good faith estimates to patients on medical bills, but some say a lack of automated solutions is going to create a colossal burden for them to meet.

Several groups have written to the Centers for Medicare & Medicaid Services (CMS) asking for more time to implement the good faith estimate portion of a rule that bans surprise medical bills. The rule, which is the subject of a broader legal fight with the healthcare industry, is set to take effect on Jan. 1, 2023.

“In light of the impending deadline and the to-date lack of guidance from CMS, we request an extension in enforcement discretion until a technical solution has been identified and implemented,” the American Hospital Association said in its letter to CMS.

The No Surprises Act signed into law last year calls for a ban on surprise medical bills and sets up an arbitration system to handle disputes between payers and providers over out-of-network charges. The law also requires providers to give uninsured or self-pay patients a “good faith estimate” of charges for care when a procedure is scheduled or upon request, according to CMS. Providers must also give estimates for certain insured patients to their plan or health insurer.

The law includes an arbitration process to handle charges that are well above the estimate.

Providers must start making these estimates available Jan. 1, but groups say the Department of Health and Human Services (HHS) has a massive misunderstanding of the infrastructure they are needed to meet the estimate requirements.

“Our members report a significant expense associated with completing [good faith estimates],” said the American Medical Group Association (AMGA) in a letter (PDF). “In addition, there is currently no realistic way to complete [good faith estimates] electronically.”

While members create workflows and infrastructure to create the estimates, they are diverting “scarce resources from other priorities,” the group added.

AMGA said providers are already short staffed due to the COVID-19 pandemic and that the current estimate requirements call for additional tasks. For instance, staff fulfilling such responsibilities need to know about coding, facilities, providers and fee schedules.

“Staff will need to be excellent communicators in order to effectively discuss [estimates] with patients,” AMGA said.

AHA added that without an automated standard for providers to rely on, they will have to each determine how to transmit the information, which can lead to major differences throughout the industry.

“Navigating a non-standardized process would place an enormous administrative burden on providers, well beyond what regulators likely considered prior to creating the implementation and enforcement dates,” the hospital group added.

AHA is working with the American Medical Association, the Medical Group Management Association and HL7 to create a workgroup on technical solutions for estimates.

CMS did not immediately return a request for comment on the requests for an extension.

The chagrin among the providers comes as the Biden administration is embroiled in another legal fight over another part of the law.

One of the rules implementing the arbitration process drew providers’ ire. The rule outlines the process for which a third-party arbiter will choose between out-of-network charges offered by the provider and payer. It calls for the arbiter to put an emphasis on the amount closest to a qualifying payment amount, which is the geographic average rate for the service.

Providers have cried foul that the rule contradicts the No Surprises Act, which does not call for use of a benchmark rate in the arbitration process. A federal judge recently vacated the arbitration process, finding that the rule does conflict with the intent of the law, but HHS has sought to appeal the ruling.


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