Author: Cait O'Donnell, PhD
NSA Series: Part 4 of 9
Exploring the Requirements and Challenges of the Good Faith Estimate
In 2020, the No Surprises Act (NSA) was passed to protect patients from surprise medical bills. According to CMS, the Act aims to “protect people from surprise medical bills and remove consumers from payment disputes between a provider or health care facility and their health plan.”
One of the ways in which the NSA intends to reduce surprise billing is through the “good faith estimate” (GFE) requirement. The NSA mandates that, in non-emergency situations, providers must give patients a GFE of their expected medical cost prior to the patient receiving their service. However, it has been found that providers are finding it difficult to comply with this mandate due to the various conditions needed to satisfy its requirements.
To meet the requirements of the GFE, providers must: determine the convening provider, contact all other potential providers or facilities that may be involved in the patient’s service and be requesting a GFE for their portion of the service, then compile the GFEs before sending them to the payer or patient (if they’re uninsured or self-pay). Fulfilling all of these steps alone is demanding enough. When you factor in the tight turnaround times of one to three days depending on when the service is scheduled, meeting the GFE requirements becomes more difficult. To add another element of complexity, we have yet to receive guidance around which standard is to be used to exchange the data between providers, facilities and payers.
To understand the challenges that providers are having around meeting the GFE requirements, WEDI surveyed 274 industry stakeholders. Of the respondents, almost 40% work in small provider clinics, while approximately 10% are from large provider clinics, health systems and medium-sized clinics respectively. The remainder work in hospitals and other provider types or other entities. The survey results showed that providers and facilities are facing significant challenges in meeting the GFE requirements of the NSA.
Attention: NSA Challenges Ahead
Meeting the GFE mandates of the NSA requires a significant organizational shift within healthcare. This demands a level of coordination across multiple providers and organizations which has not been established widely across the industry. It’s this reason that 91.5% of WEDI respondents said that it would be difficult for the convening provider or facility to collect GFEs from co-providers or facilities for the specific medical service. At the same time, 89% of respondents said it would be difficult to provide patients with completed GFEs within the required three business days, citing factors such as slow post services causing potential delays.
According to some physician advocacy groups, these requirements will lead to excess work for physicians and hospitals. For example, the Massachusetts Medical Society sent comments to CMS about potential provider strain expressing “serious concerns about the burden placed on providers due to the GFE process, especially the burden on the convening provider and the impact these burdens will have on physician practices as these requirements are enforced.” Their difficulty navigating GFEs is only exacerbated by pandemic pressures, the amount of information required to be sent, as well as the fast turnaround times in which information is expected to be delivered.
Responding to the COVID-19 pandemic put new pressures on an already strained healthcare sector. New screening processes, extensive cleaning protocols and employee redeployment required enormous change management and caused long-lasting disruption. Besides the logistical demands, the pandemic has also taken a mental and emotional toll on providers. A 2022 study measured trends in burnout in hospital staff over 12 months of the pandemic. The study observed that “rates of high emotional exhaustion in nurses and other healthcare professionals remained higher than what was typically measured in hospital-based healthcare workers prior to the pandemic.” Understandably, implementing technical changes has not been a priority for healthcare providers during this time.
The pandemic has also deepened worker shortages. Due to the amount of work attached to creating GFEs, providers may be forced to hire staff primarily to create GFEs for patients. But with some practices already struggling to maintain adequate clinical and office staff due to worker shortages, the added administrative burden created by GFE requirements could become quite problematic.
Substantial Information Required
The GFE includes many data elements, including patient name, date of birth, itemized list of services (grouped by provider or facility), diagnosis codes, services codes and charges. It also requires the name, NPI and TIN of each provider and facility where care will be provided. Currently, the estimate isn’t required to include items and services facilitated by another provider or facility. However, in 2023, the provider or facility will be required to supply co-provider or co-facility cost information. At that point, convening providers may struggle to include all required information, such as the NPI or TIN for co-facilities, or accurate diagnosis and service codes from ancillary providers.
Fast Turnaround Times
The timeline for creating GFEs is short. Providers or facilities must provide a GFE no later than one business day if the service is scheduled within ten business days, or three days if the service is scheduled for more than 10 business days in advance (or the patient makes the request). Absent a standardized method to quickly generate GFEs, these timelines may prove arduous for convenors who need to pull together information from several sources. When commenting on the survey mentioned above, WEDI’s Vice President of Federal Affairs noted that “respondents were adamant that meeting the legislation’s 3-day deadline to get the GFE to the patient would be difficult or very difficult.”
The Need for Standardized Data Exchange: Using FHIR to Light the Way
Regardless of pandemic pressures, the technical aspects alone of these requirements are complex and difficult to meet. In an industry that still uses fax machines, it will take a lot of effort to facilitate the rapid and secure exchange of sensitive healthcare data across multiple applications.
Currently, departments have not mandated one standard or format for how this data should be exchanged between convening and supporting providers, facilities and health plans. WEDI addressed these challenges in a statement: "absent a standardized methodology, the industry will inevitably develop one-off proprietary solutions that will severely tax providers and facilities and potentially delay patient access to this information."
As part of their comments to CMS mentioned above, the Massachusetts Medical Society recommended “an automated and standardized electronic tool for providers to transmit cost estimate requests and information to other providers and to insurers (for the Advanced Explanation of Benefits).” Without this tool, they warned, providers would likely develop their own manual workflows—leading to inconsistency in information and further administrative burden.
It’s clear that a solution is needed to help with this current state of unstandardized data exchange and address providers’ concerns about meeting these new requirements in such short time frames. We believe that Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) may be the solution to facilitate the data exchange process and assist providers and facilities in meeting the requirements surrounding the GFE. As a mature standard for global health data interoperability, FHIR can be used to help combat these challenges. Once the organizational challenges of the GFE have been dealt with, FHIR can be used to address the technical aspects of implementation so that data can be efficiently and securely exchanged. FHIR enables interoperability within healthcare, resulting in better global health.
Today’s providers are stretched thin—and the uncertainties surrounding the GFE requirements only add an additional burden to an already strained industry. This is one of the reasons why 83.1% of WEDI survey respondents were supportive of the government delaying the GFE requirement. However, introducing a standardized data exchange could help solve many of the technical obstacles blocking GFE adoption by enabling seamless communication between providers and their co-providers or co-facilities. Mandating a single standard would remove one element of uncertainty and replace it with a path around many of the technical obstacles holding back GFEs. We hope that FHIR will be that standard, providing the data exchange needed to ease some of the burdens felt throughout healthcare.
Read our series of blogs below to continue learning about NSA.
Part 1: Implications of NSA
Part 4: An Honest Assessment of NSA
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