In a September 16, 2022, publication, the federal government asked stakeholders to provide feedback on the implementation of good faith estimates (GFEs), which were created by the No Surprises Act. Comments will close on November 15, 2022.
In the request for information, federal regulators indicated that enforcement is pending related to GFEs for covered individuals.
Regulators also included a number of other questions for stakeholders, including:
“Are there any approaches that the Departments and OPM should consider, or flexibility that should be provided (such as an exception or a phased-in approach to requiring providers and payers to adopt a standards-based API to exchange AEOB and GFE data), to account for small, rural, or other providers, facilities, plans, issuers, and carriers?”
“In addition to issues related to how providers and facilities would transfer GFEs to plans, issuers, and carriers, there are also issues related to ensuring that providers and facilities transfer the necessary data for plans, issuers, and carriers to prepare accurate AEOBs that take into account how the No Surprises Act’s or a State’s surprise billing laws may affect an individual’s benefits related to the items or services specified in the AEOB, and the individual’s financial responsibility for these items or services.”
“Should a nonparticipating provider of nonemergency services be required to inform a plan, issuer, or carrier, as part of or concurrently with the GFE, whether the requested or scheduled items or services would be furnished with respect to the individual’s visit to a participating facility? Should this requirement depend on whether the GFE was requested, as opposed to whether the furnishing of the items or services has been scheduled?”
“The Departments and OPM are interested in plans’, issuers’, and carriers’ perspectives on whether a diagnosis code would be required for the calculation of the AEOB. Are there items or services for which a plan, issuer, or carrier would not be able to determine points of information such as: (1) the contracted rate; (2) the coverage level (that is, if the plan or issuer covers an item or service associated with one diagnosis at a higher rate than an item or service associated with another); or (3) whether an item or service is covered (that is, if the item or service is covered for one diagnosis but not another) for an item or service based on the service code and other information in the GFE in the absence of a diagnosis code?”
“Would it alleviate burden to allow providers and facilities, for purposes of verifying coverage, to rely on an individual’s representation regarding whether the individual is enrolled in a health plan or coverage and seeking to have a claim for the items or services submitted to the plan or coverage? What might be the implications of taking this approach?”