1.
www.compliantfqhc.com
Continuous Compliance Series-
Deep Dive into Good Faith Estimate
COMPLIATRIC WEBINAR SERIES
Presented by: Tonya Harris
tonyaharris846@gmail.com

2.
CONTINUOUS COMPLIANCE
Good Faith Estimate

3.
DISCLAIMERS
This presentation is not endorsed by Management Strategists Consulting
Group (MSCG)
This presentation is not endorsed by Health Resources Services
Administration (HRSA) or Bureau of Primary Health Care (BPHC)
Not employed by MSCG or BPHC
Independent Consultant who is contracted to do Operational SiteVisits
(OSV)s and Technical Assistance (TA)
Not intended to provide legal advice

4.
AGENDA
BACKGROUND &
OVERVIEW
REQUIREMENTS IMPLEMENTATION

5.
BACKGROUND & OVERVIEW
The No Surprise Act
• Enacted December 2021
• Focus on High-Cost Services and Providers
• Very detailed and overly ambitious deadlines
• Most provisions do not apply to FQHCs, some DO apply
• Phase 1 Effective January 1, 2022
• CMS accepted comments on the rule through December 6 and may make
changes.
• Requested information
• Impact on small rural providers
• Alternatives that “could meet the statutory requirement”

6.
BACKGROUND & OVERVIEW
Surprise!
• Interim Final Rule (IFR) requires health care providers (including
FQHCs) to provide uninsured and self-pay patients with a Good
Faith Estimate (GFE) of their expected out-of-pocket charges:
• When requested, OR
• For appointments scheduled at least 3 business days in advance
Even if patient does not request it

7.
BACKGROUND & OVERVIEW
Challenges for FQHCs
• Large Uninsured/Self Pay patient base
• Patient must receive GFE every time they schedule an appointment at least
3 days in advance, even if they know exactly what the charge will be
• The estimate can be given orally, but it must also be written
• GFEs may be given to patients with recurring appointments
• Must include timeframes, frequency and total number of recurring
items/services (maximum 12 months)
• Requires diagnosis on GFE, even if new patient
• Enforcement mechanism doesn’t apply unless a GFE understates actual
charges by at least $400
• GFEs will not be reviewed as part of the OSV

8.
REQUIREMENTS
What
• Included Services & Items Subject to GFE
• All types of health care services. May include:
• Medical
• Dental
• Behavioral health
• Vision
• Related Items Presumed
• Dentures
• Eyeglasses
• Prescription drugs
• Durable medical equipment

9.
REQUIREMENTS
Who
• Receive GFE
• Uninsured
• Patient is considered Uninsured if they meet any of the following:
• They have no insurance
• Non-covered service
• Short-term limited duration plan
• Self Pay
• Patient has insurance coverage but indicate they do not plan to submit a
bill for the service to their insurer

10.
Time Frame
If an Uninsured or Self Pay Patient GFE Required
IF
Schedules an
appointment
Less than 3 business days
in advance
No
Between 3 to 9 business days
in advance
Yes, within 1 business day of
scheduling
10 or more days in advance Yes, within 3 business days of
scheduling
Requests a GFE, or
otherwise ask about cost of
a service, but does not
schedule an appointment
Yes, within 3 business days of
the request
Schedule the same service
on a recurrent basis
(multiple dental
appointments, treatment
plan)
A Single GFE can be issued for
recurring services/items,
maximum 12 months
REQUIREMENTS

11.
REQUIREMENTS
When
• GFE must be given
• Anytime an uninsured patient asks any employee of the agency. Including, but
not limited to:
• Physicians
• Nurses
• Outreach workers
• Clerical staff
• If appointment is scheduled at least 3 days in advance

12.
REQUIREMENTS
Notices & Documentation
• Notices must be
• Written in a clear, understandable manner
• Prominently displayed
• In the office
• On-site where scheduling or questions about the cost of items occur
• On CHC’s website
• Must be easily searchable

13.
REQUIREMENTS
Delivery & Record Keeping
• GFEs must be
• Provided to the patient or authorized representative in written form
• Paper
• Electronically – as long as the patient can “print” the document
• Patient Portal
• Included in the patient’s medical record
• Available upon request for at least 6 years

14.
REQUIREMENTS
GFE For Provider
Requirements
Effective Date CMS will begin
enforcement
Phase one Uninsured & Self
Pay patients
GFE must include
charge information
for services/items
provided by CHC
Jan 1, 2022 Jan 1, 2022
Phase two Uninsured & Self
Pay Patients
GFE must include
charge information
from outside
providers
Jan 1, 2022 Jan 1, 2023
Phase three Insured patients Providers must
send GFE
information to
insurance
companies of
insured patients
POSTPONED the
requirements
indefinitely – citing
Technological issues
POSTPONED
Implementation

15.
REQUIREMENTS
Enforcement
• Patients whose charges are greater than $400 above the GFE can dispute charges
through a resolution process

16.
IMPLEMENTATION
Making a Good Faith Effort
• Option #1
• Follow the regulation as written
• Develop process to merge GFE rules with BPHC Sliding Fee rules and
• Document places where the GFE rule does not fit
• Option #2
• Issue GFEs only when a patient requests one
• Ensure that patients are informed that they can request a GFE
• Option #3
• Issue GFE only when a patient’s charge might reach $400 (threshold to trigger dispute process)
• Option #4
• Wait until CMS revises the regulation to take action and then comply with the revised rule
Assumption is that when CMS issues update rule, CHCs will come into compliance ASAP

17.
IMPLEMENTATION
Other Considerations
• Prioritize charges that possibly could exceed the $400
• Focus only on Phase 1
• Use “recurring appointment” as often as you can
• Consider the definition of self-pay patients
• BPHC – A person whose out-of-pocket cost under their insurance is higher than what
they would pay under the Sliding fee Scale
• GFE – A person who has insurance but chooses not to submit a bill

18.
IMPLEMENTATION
Policy & Procedure Development
• Focus on how FQHCs avoid Surprise Billing
• Compliance with requirements under Section 330 of the Public Health Act
• Sliding Fee Discount Program is available to ALL patients
• SFDP ensures that patients below 200% FPG have reduced fees to ensure
affordability
• No patient is denied service based on the inability to pay
• CHCs are not required to offer SFDP on supplies (i.e. dentures, eyeglasses,
prescription drugs), however, CHC is required to notify patients of out-of-
pocket cost

19.
IMPLEMENTATION
Policy & Procedure Development
• When Providing a Good Faith Estimate
• Staff may lack adequate or appropriate information about the patient’s needs
• The need for some services/items cannot be determined until the patient meets
clinician
• The price of some items, particularly prescription drugs, can change significantly
in a short time period
• Despite our good faith efforts, a patient’s actual charges may differ from what is
listed on GFE
• Staff will not know diagnosis codes for patients and will not include it

20.
IMPLEMENTATION
Policy & Procedure Development
• Prescription Drugs
• Indicate that drug prices change rapidly and that the prices listed on GFE could
change
• 340B Program

21.
IMPLEMENTATION
Policy & Procedure Development
Procedure may include options provided earlier or any combination.
Option #1 Option #1
Follow the regulation as written
• Develop process to merge GFE rules
with BPHC Sliding Fee rules and
• Document places where the GFE rule
does not fit
Option #2 Issue GFEs only at patient requests one • Ensure that patients are informed that they
can request a GFE
Option #3 Issue GFE only when a patient’s charge
might reach $400
• threshold to trigger dispute process
Option #4 Wait until CMS revised the regulation to
take action
• and then comply with the revised rule

22.
IMPLEMENTATION
Adjustments
• Not included for CHC
• Costs associated with outside providers (technically required 1/1/2022; will not be
enforced until 1/1/2023)
• Charge Adjustments
• Sliding fee
• When sliding fee pay known, staff will provide charge data specific to that class.
Example: Patient qualifies for the lowest slide level and the nominal fee is $20, the
GFE would reflect $20.
• When sliding fee pay class is unknown you will need to give a range of charges.
Example: If the full charge is estimated at $100, GFE would state charges between
$20 - $100.
• Prompt pay discounts will need to be considered (if available)

23.
IMPLEMENTATION
Forms
• GFE must include
• Patient name, date of birth, date/time/location of appointment
• Disclaimer language
• Charge information for services and items to be provided
• Exact dollar amount the patient will pay – even if patient hasn’t been
screened for SFDP
• Diagnosis codes and their meanings in plain English
• Medicare has sample form on their website
• E.H.R./P.M. systems should have GFE form

24.
QUESTIONS?

25.
RESOURCES
Centers for Medicare &
Medicaid Services (CMS)
• https://www.cms.gov/
NACHC-Health Center
Resource Clearinghouse
• https://www.healthcenterinfo.org/
State Primary Care
Associations