SlideShare a Scribd company logo
1 of 25
Download to read offline
www.compliantfqhc.com
Continuous Compliance Series-
Deep Dive into Good Faith Estimate
COMPLIATRIC WEBINAR SERIES
Presented by: Tonya Harris
tonyaharris846@gmail.com
CONTINUOUS COMPLIANCE
Good Faith Estimate
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
AGENDA
BACKGROUND &
OVERVIEW
REQUIREMENTS IMPLEMENTATION
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”
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
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
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
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
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
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
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
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
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
REQUIREMENTS
Enforcement
• Patients whose charges are greater than $400 above the GFE can dispute charges
through a resolution process
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
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
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
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
IMPLEMENTATION
Policy & Procedure Development
• Prescription Drugs
• Indicate that drug prices change rapidly and that the prices listed on GFE could
change
• 340B Program
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
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)
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
QUESTIONS?
RESOURCES
Centers for Medicare &
Medicaid Services (CMS)
• https://www.cms.gov/
NACHC-Health Center
Resource Clearinghouse
• https://www.healthcenterinfo.org/
State Primary Care
Associations

More Related Content

Similar to 2022 compliatric special webinar deep dive into good faith estimate

2023 Compliatric Webinar Series - Making the Most out of the Sliding Fee Prog...
2023 Compliatric Webinar Series - Making the Most out of the Sliding Fee Prog...2023 Compliatric Webinar Series - Making the Most out of the Sliding Fee Prog...
2023 Compliatric Webinar Series - Making the Most out of the Sliding Fee Prog...Compliatric Where Compliance Happens
 
68788 health care reform health plans overview 2 14-13
68788 health care reform health plans overview 2 14-1368788 health care reform health plans overview 2 14-13
68788 health care reform health plans overview 2 14-13Jerry Whitaker CIC,CRIS
 
Practical Solutions for Managing the Coverage Gap Discount Program
Practical Solutions for Managing the Coverage Gap Discount Program Practical Solutions for Managing the Coverage Gap Discount Program
Practical Solutions for Managing the Coverage Gap Discount Program Paragon Solutions
 
Making sure your bad debts pass medicare audits
Making sure your bad debts pass medicare auditsMaking sure your bad debts pass medicare audits
Making sure your bad debts pass medicare auditsDebby Sieradzki
 
Unit 517 lecture notes no 5
Unit 517 lecture notes no 5Unit 517 lecture notes no 5
Unit 517 lecture notes no 50725303890
 
The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Co...
The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Co...The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Co...
The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Co...PYA, P.C.
 
Real World Issues with Implementing Compliant Financial Assistance and Billin...
Real World Issues with Implementing Compliant Financial Assistance and Billin...Real World Issues with Implementing Compliant Financial Assistance and Billin...
Real World Issues with Implementing Compliant Financial Assistance and Billin...PYA, P.C.
 
Health Care Reform: An Update
Health Care Reform: An UpdateHealth Care Reform: An Update
Health Care Reform: An Updateweatrust
 
Insights2020 Covid-19 Ep. 6
Insights2020 Covid-19 Ep. 6Insights2020 Covid-19 Ep. 6
Insights2020 Covid-19 Ep. 6Ben Quirk
 
COVID-19 Support: Avoiding Telehealth Documentation Woes
COVID-19 Support: Avoiding Telehealth Documentation WoesCOVID-19 Support: Avoiding Telehealth Documentation Woes
COVID-19 Support: Avoiding Telehealth Documentation WoesHealthcare Resource Group Inc.
 
Unpacking the No Surprises Act Webinar
Unpacking the No Surprises Act WebinarUnpacking the No Surprises Act Webinar
Unpacking the No Surprises Act WebinarZelis Payments
 
Getting Paid in 2022: Adapting your Practice to Thrive Within the Healthcare ...
Getting Paid in 2022: Adapting your Practice to Thrive Within the Healthcare ...Getting Paid in 2022: Adapting your Practice to Thrive Within the Healthcare ...
Getting Paid in 2022: Adapting your Practice to Thrive Within the Healthcare ...Kareo
 
9 Compliance Tips to Start the Year Right
9 Compliance Tips to Start the Year Right9 Compliance Tips to Start the Year Right
9 Compliance Tips to Start the Year RightMD Ranger, Inc.
 
CARES Act - Key Takeaways for Healthcare Organizations
CARES Act - Key Takeaways for Healthcare OrganizationsCARES Act - Key Takeaways for Healthcare Organizations
CARES Act - Key Takeaways for Healthcare OrganizationsCitrin Cooperman
 
Elder Law in 2017 Review
Elder Law in 2017 ReviewElder Law in 2017 Review
Elder Law in 2017 ReviewHazen Law Group
 
Denial management presentation
Denial management   presentationDenial management   presentation
Denial management presentationLeanmedicalbilling
 

Similar to 2022 compliatric special webinar deep dive into good faith estimate (20)

2023 Compliatric Webinar Series - Making the Most out of the Sliding Fee Prog...
2023 Compliatric Webinar Series - Making the Most out of the Sliding Fee Prog...2023 Compliatric Webinar Series - Making the Most out of the Sliding Fee Prog...
2023 Compliatric Webinar Series - Making the Most out of the Sliding Fee Prog...
 
68788 health care reform health plans overview 2 14-13
68788 health care reform health plans overview 2 14-1368788 health care reform health plans overview 2 14-13
68788 health care reform health plans overview 2 14-13
 
Practical Solutions for Managing the Coverage Gap Discount Program
Practical Solutions for Managing the Coverage Gap Discount Program Practical Solutions for Managing the Coverage Gap Discount Program
Practical Solutions for Managing the Coverage Gap Discount Program
 
Making sure your bad debts pass medicare audits
Making sure your bad debts pass medicare auditsMaking sure your bad debts pass medicare audits
Making sure your bad debts pass medicare audits
 
Unit 517 lecture notes no 5
Unit 517 lecture notes no 5Unit 517 lecture notes no 5
Unit 517 lecture notes no 5
 
The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Co...
The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Co...The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Co...
The PPS [Prospective Payment System] to PDPM Pendulum: An Analysis of PDPM Co...
 
Strating Urgent Care
Strating Urgent CareStrating Urgent Care
Strating Urgent Care
 
Real World Issues with Implementing Compliant Financial Assistance and Billin...
Real World Issues with Implementing Compliant Financial Assistance and Billin...Real World Issues with Implementing Compliant Financial Assistance and Billin...
Real World Issues with Implementing Compliant Financial Assistance and Billin...
 
Health Care Reform: An Update
Health Care Reform: An UpdateHealth Care Reform: An Update
Health Care Reform: An Update
 
Insights2020 Covid-19 Ep. 6
Insights2020 Covid-19 Ep. 6Insights2020 Covid-19 Ep. 6
Insights2020 Covid-19 Ep. 6
 
COVID-19 Support: Avoiding Telehealth Documentation Woes
COVID-19 Support: Avoiding Telehealth Documentation WoesCOVID-19 Support: Avoiding Telehealth Documentation Woes
COVID-19 Support: Avoiding Telehealth Documentation Woes
 
Unpacking the No Surprises Act Webinar
Unpacking the No Surprises Act WebinarUnpacking the No Surprises Act Webinar
Unpacking the No Surprises Act Webinar
 
Getting Paid in 2022: Adapting your Practice to Thrive Within the Healthcare ...
Getting Paid in 2022: Adapting your Practice to Thrive Within the Healthcare ...Getting Paid in 2022: Adapting your Practice to Thrive Within the Healthcare ...
Getting Paid in 2022: Adapting your Practice to Thrive Within the Healthcare ...
 
2022 Compliatric HRSA Chapter 9 Sliding Fee Discount Program
2022 Compliatric HRSA Chapter 9 Sliding Fee Discount Program2022 Compliatric HRSA Chapter 9 Sliding Fee Discount Program
2022 Compliatric HRSA Chapter 9 Sliding Fee Discount Program
 
9 Compliance Tips to Start the Year Right
9 Compliance Tips to Start the Year Right9 Compliance Tips to Start the Year Right
9 Compliance Tips to Start the Year Right
 
CARES Act - Key Takeaways for Healthcare Organizations
CARES Act - Key Takeaways for Healthcare OrganizationsCARES Act - Key Takeaways for Healthcare Organizations
CARES Act - Key Takeaways for Healthcare Organizations
 
Stark Law Basics
Stark Law BasicsStark Law Basics
Stark Law Basics
 
The Health Care Law and You
The Health Care Law and YouThe Health Care Law and You
The Health Care Law and You
 
Elder Law in 2017 Review
Elder Law in 2017 ReviewElder Law in 2017 Review
Elder Law in 2017 Review
 
Denial management presentation
Denial management   presentationDenial management   presentation
Denial management presentation
 

More from Compliatric Where Compliance Happens

2024 Compliatric Webinar Series - Managing and Protecting Adverse Patient Eve...
2024 Compliatric Webinar Series - Managing and Protecting Adverse Patient Eve...2024 Compliatric Webinar Series - Managing and Protecting Adverse Patient Eve...
2024 Compliatric Webinar Series - Managing and Protecting Adverse Patient Eve...Compliatric Where Compliance Happens
 
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion April 202...
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion April 202...2024 Compliatric Webinar Series - OSV Overview and Panel Discussion April 202...
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion April 202...Compliatric Where Compliance Happens
 
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdfCompliatric Where Compliance Happens
 
2024 Compliatric Webinar Series - Next-Gen Compliance- Leveraging OIG's Recen...
2024 Compliatric Webinar Series - Next-Gen Compliance- Leveraging OIG's Recen...2024 Compliatric Webinar Series - Next-Gen Compliance- Leveraging OIG's Recen...
2024 Compliatric Webinar Series - Next-Gen Compliance- Leveraging OIG's Recen...Compliatric Where Compliance Happens
 
2024 Compliatric Webinar Series - Components of a Needs Assessment.pdf
2024 Compliatric Webinar Series - Components of a Needs Assessment.pdf2024 Compliatric Webinar Series - Components of a Needs Assessment.pdf
2024 Compliatric Webinar Series - Components of a Needs Assessment.pdfCompliatric Where Compliance Happens
 
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion.pdf
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion.pdf2024 Compliatric Webinar Series - OSV Overview and Panel Discussion.pdf
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion.pdfCompliatric Where Compliance Happens
 
2023 Compliatric Webinar Series - Unveiling the Blueprint_ The Components of ...
2023 Compliatric Webinar Series - Unveiling the Blueprint_ The Components of ...2023 Compliatric Webinar Series - Unveiling the Blueprint_ The Components of ...
2023 Compliatric Webinar Series - Unveiling the Blueprint_ The Components of ...Compliatric Where Compliance Happens
 
2023 Compliatric Webinar Series - Contracts and Memorandums of Understanding ...
2023 Compliatric Webinar Series - Contracts and Memorandums of Understanding ...2023 Compliatric Webinar Series - Contracts and Memorandums of Understanding ...
2023 Compliatric Webinar Series - Contracts and Memorandums of Understanding ...Compliatric Where Compliance Happens
 
Contracts and Memorandums of Understanding - Requirements and Responsibilities
Contracts and Memorandums of Understanding - Requirements and ResponsibilitiesContracts and Memorandums of Understanding - Requirements and Responsibilities
Contracts and Memorandums of Understanding - Requirements and ResponsibilitiesCompliatric Where Compliance Happens
 
2023 Compliatric Webinar Series - Developing Strong Board and CEO Relationshi...
2023 Compliatric Webinar Series - Developing Strong Board and CEO Relationshi...2023 Compliatric Webinar Series - Developing Strong Board and CEO Relationshi...
2023 Compliatric Webinar Series - Developing Strong Board and CEO Relationshi...Compliatric Where Compliance Happens
 
2023 Compliatric Webinar Series - Overview of CARF Accreditation.pdf
2023 Compliatric Webinar Series - Overview of CARF Accreditation.pdf2023 Compliatric Webinar Series - Overview of CARF Accreditation.pdf
2023 Compliatric Webinar Series - Overview of CARF Accreditation.pdfCompliatric Where Compliance Happens
 
2023 Compliatric Webinar Series - Are You Ready for an OSHA Inspection.pdf
2023 Compliatric Webinar Series - Are You Ready for an OSHA Inspection.pdf2023 Compliatric Webinar Series - Are You Ready for an OSHA Inspection.pdf
2023 Compliatric Webinar Series - Are You Ready for an OSHA Inspection.pdfCompliatric Where Compliance Happens
 
2023 Compliatric Webinar Series - Good Faith Estimates_Don't Let the No Surpr...
2023 Compliatric Webinar Series - Good Faith Estimates_Don't Let the No Surpr...2023 Compliatric Webinar Series - Good Faith Estimates_Don't Let the No Surpr...
2023 Compliatric Webinar Series - Good Faith Estimates_Don't Let the No Surpr...Compliatric Where Compliance Happens
 
2023 Compliatric Webinar Series - Your Accreditation Journey - Challenges Alo...
2023 Compliatric Webinar Series - Your Accreditation Journey - Challenges Alo...2023 Compliatric Webinar Series - Your Accreditation Journey - Challenges Alo...
2023 Compliatric Webinar Series - Your Accreditation Journey - Challenges Alo...Compliatric Where Compliance Happens
 
2023 Compliatric Webinar Series - Active Shooter Training and Exercises.pdf
2023 Compliatric Webinar Series - Active Shooter Training and Exercises.pdf2023 Compliatric Webinar Series - Active Shooter Training and Exercises.pdf
2023 Compliatric Webinar Series - Active Shooter Training and Exercises.pdfCompliatric Where Compliance Happens
 
Compliatric Webinar Your Accreditation Journey Best Path Forward 7.25.2023.pdf
Compliatric Webinar Your Accreditation Journey Best Path Forward 7.25.2023.pdfCompliatric Webinar Your Accreditation Journey Best Path Forward 7.25.2023.pdf
Compliatric Webinar Your Accreditation Journey Best Path Forward 7.25.2023.pdfCompliatric Where Compliance Happens
 
2023 Compliatric Webinar Series - Developing a Pathway for Promotion & Leader...
2023 Compliatric Webinar Series - Developing a Pathway for Promotion & Leader...2023 Compliatric Webinar Series - Developing a Pathway for Promotion & Leader...
2023 Compliatric Webinar Series - Developing a Pathway for Promotion & Leader...Compliatric Where Compliance Happens
 
2023 Compliatric Webinar Series Strategic Planning Webinar 06_20_2023.pptx
2023 Compliatric Webinar Series Strategic Planning Webinar 06_20_2023.pptx2023 Compliatric Webinar Series Strategic Planning Webinar 06_20_2023.pptx
2023 Compliatric Webinar Series Strategic Planning Webinar 06_20_2023.pptxCompliatric Where Compliance Happens
 
2023 Compliatric Webinar Series - The Basics of Disaster Preparedness.pdf
2023 Compliatric Webinar Series - The Basics of Disaster Preparedness.pdf2023 Compliatric Webinar Series - The Basics of Disaster Preparedness.pdf
2023 Compliatric Webinar Series - The Basics of Disaster Preparedness.pdfCompliatric Where Compliance Happens
 

More from Compliatric Where Compliance Happens (20)

2024 Compliatric Webinar Series - Managing and Protecting Adverse Patient Eve...
2024 Compliatric Webinar Series - Managing and Protecting Adverse Patient Eve...2024 Compliatric Webinar Series - Managing and Protecting Adverse Patient Eve...
2024 Compliatric Webinar Series - Managing and Protecting Adverse Patient Eve...
 
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion April 202...
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion April 202...2024 Compliatric Webinar Series - OSV Overview and Panel Discussion April 202...
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion April 202...
 
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf
2024 Compliatric Webianr Series - Contracts and MOUs from a HRSA Perspective.pdf
 
2024 Compliatric Webinar Series - Protecting LGBTQ Patients.pdf
2024 Compliatric Webinar Series - Protecting LGBTQ Patients.pdf2024 Compliatric Webinar Series - Protecting LGBTQ Patients.pdf
2024 Compliatric Webinar Series - Protecting LGBTQ Patients.pdf
 
2024 Compliatric Webinar Series - Next-Gen Compliance- Leveraging OIG's Recen...
2024 Compliatric Webinar Series - Next-Gen Compliance- Leveraging OIG's Recen...2024 Compliatric Webinar Series - Next-Gen Compliance- Leveraging OIG's Recen...
2024 Compliatric Webinar Series - Next-Gen Compliance- Leveraging OIG's Recen...
 
2024 Compliatric Webinar Series - Components of a Needs Assessment.pdf
2024 Compliatric Webinar Series - Components of a Needs Assessment.pdf2024 Compliatric Webinar Series - Components of a Needs Assessment.pdf
2024 Compliatric Webinar Series - Components of a Needs Assessment.pdf
 
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion.pdf
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion.pdf2024 Compliatric Webinar Series - OSV Overview and Panel Discussion.pdf
2024 Compliatric Webinar Series - OSV Overview and Panel Discussion.pdf
 
2023 Compliatric Webinar Series - Unveiling the Blueprint_ The Components of ...
2023 Compliatric Webinar Series - Unveiling the Blueprint_ The Components of ...2023 Compliatric Webinar Series - Unveiling the Blueprint_ The Components of ...
2023 Compliatric Webinar Series - Unveiling the Blueprint_ The Components of ...
 
2023 Compliatric Webinar Series - Contracts and Memorandums of Understanding ...
2023 Compliatric Webinar Series - Contracts and Memorandums of Understanding ...2023 Compliatric Webinar Series - Contracts and Memorandums of Understanding ...
2023 Compliatric Webinar Series - Contracts and Memorandums of Understanding ...
 
Contracts and Memorandums of Understanding - Requirements and Responsibilities
Contracts and Memorandums of Understanding - Requirements and ResponsibilitiesContracts and Memorandums of Understanding - Requirements and Responsibilities
Contracts and Memorandums of Understanding - Requirements and Responsibilities
 
2023 Compliatric Webinar Series - Developing Strong Board and CEO Relationshi...
2023 Compliatric Webinar Series - Developing Strong Board and CEO Relationshi...2023 Compliatric Webinar Series - Developing Strong Board and CEO Relationshi...
2023 Compliatric Webinar Series - Developing Strong Board and CEO Relationshi...
 
2023 Compliatric Webinar Series - Overview of CARF Accreditation.pdf
2023 Compliatric Webinar Series - Overview of CARF Accreditation.pdf2023 Compliatric Webinar Series - Overview of CARF Accreditation.pdf
2023 Compliatric Webinar Series - Overview of CARF Accreditation.pdf
 
2023 Compliatric Webinar Series - Are You Ready for an OSHA Inspection.pdf
2023 Compliatric Webinar Series - Are You Ready for an OSHA Inspection.pdf2023 Compliatric Webinar Series - Are You Ready for an OSHA Inspection.pdf
2023 Compliatric Webinar Series - Are You Ready for an OSHA Inspection.pdf
 
2023 Compliatric Webinar Series - Good Faith Estimates_Don't Let the No Surpr...
2023 Compliatric Webinar Series - Good Faith Estimates_Don't Let the No Surpr...2023 Compliatric Webinar Series - Good Faith Estimates_Don't Let the No Surpr...
2023 Compliatric Webinar Series - Good Faith Estimates_Don't Let the No Surpr...
 
2023 Compliatric Webinar Series - Your Accreditation Journey - Challenges Alo...
2023 Compliatric Webinar Series - Your Accreditation Journey - Challenges Alo...2023 Compliatric Webinar Series - Your Accreditation Journey - Challenges Alo...
2023 Compliatric Webinar Series - Your Accreditation Journey - Challenges Alo...
 
2023 Compliatric Webinar Series - Active Shooter Training and Exercises.pdf
2023 Compliatric Webinar Series - Active Shooter Training and Exercises.pdf2023 Compliatric Webinar Series - Active Shooter Training and Exercises.pdf
2023 Compliatric Webinar Series - Active Shooter Training and Exercises.pdf
 
Compliatric Webinar Your Accreditation Journey Best Path Forward 7.25.2023.pdf
Compliatric Webinar Your Accreditation Journey Best Path Forward 7.25.2023.pdfCompliatric Webinar Your Accreditation Journey Best Path Forward 7.25.2023.pdf
Compliatric Webinar Your Accreditation Journey Best Path Forward 7.25.2023.pdf
 
2023 Compliatric Webinar Series - Developing a Pathway for Promotion & Leader...
2023 Compliatric Webinar Series - Developing a Pathway for Promotion & Leader...2023 Compliatric Webinar Series - Developing a Pathway for Promotion & Leader...
2023 Compliatric Webinar Series - Developing a Pathway for Promotion & Leader...
 
2023 Compliatric Webinar Series Strategic Planning Webinar 06_20_2023.pptx
2023 Compliatric Webinar Series Strategic Planning Webinar 06_20_2023.pptx2023 Compliatric Webinar Series Strategic Planning Webinar 06_20_2023.pptx
2023 Compliatric Webinar Series Strategic Planning Webinar 06_20_2023.pptx
 
2023 Compliatric Webinar Series - The Basics of Disaster Preparedness.pdf
2023 Compliatric Webinar Series - The Basics of Disaster Preparedness.pdf2023 Compliatric Webinar Series - The Basics of Disaster Preparedness.pdf
2023 Compliatric Webinar Series - The Basics of Disaster Preparedness.pdf
 

Recently uploaded

Mike Lowe’s cancer fight lowe strong shirt
Mike Lowe’s cancer fight lowe strong shirtMike Lowe’s cancer fight lowe strong shirt
Mike Lowe’s cancer fight lowe strong shirtrahman018755
 
The Docs PPG - 30.01.2024.pptx..........
The Docs PPG - 30.01.2024.pptx..........The Docs PPG - 30.01.2024.pptx..........
The Docs PPG - 30.01.2024.pptx..........TheDocs
 
Lactation Mraining Management Session-2-Comm-Building-Conf.ppt
Lactation Mraining Management  Session-2-Comm-Building-Conf.pptLactation Mraining Management  Session-2-Comm-Building-Conf.ppt
Lactation Mraining Management Session-2-Comm-Building-Conf.pptMedidas Medical Center INC
 
Digital Healthcare: The Future of Medical Consultations
Digital Healthcare: The Future of Medical ConsultationsDigital Healthcare: The Future of Medical Consultations
Digital Healthcare: The Future of Medical Consultationssmartcare
 
Clinical pharmacy book by parthasarathi.pdf
Clinical pharmacy book by  parthasarathi.pdfClinical pharmacy book by  parthasarathi.pdf
Clinical pharmacy book by parthasarathi.pdfDr. Afreen Nasir
 
Homeopathy Medicine for Diabetes_ Balancing Blood Sugar .pdf
Homeopathy Medicine for Diabetes_ Balancing Blood Sugar .pdfHomeopathy Medicine for Diabetes_ Balancing Blood Sugar .pdf
Homeopathy Medicine for Diabetes_ Balancing Blood Sugar .pdfDharma Homoeopathy
 
2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdf
2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdf2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdf
2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdfRobert Cole
 
Sugar Medicine_ Natural Homeopathy Remedies for Blood Sugar Management.pdf
Sugar Medicine_ Natural Homeopathy Remedies for Blood Sugar Management.pdfSugar Medicine_ Natural Homeopathy Remedies for Blood Sugar Management.pdf
Sugar Medicine_ Natural Homeopathy Remedies for Blood Sugar Management.pdfDharma Homoeopathy
 
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...Levi Shapiro
 
Importance of Diet on Dental Health.docx
Importance of Diet on Dental Health.docxImportance of Diet on Dental Health.docx
Importance of Diet on Dental Health.docxSachin Mittal
 
Jesse Jhaj: Building Relationships with Patients as a Doctor or Healthcare Wo...
Jesse Jhaj: Building Relationships with Patients as a Doctor or Healthcare Wo...Jesse Jhaj: Building Relationships with Patients as a Doctor or Healthcare Wo...
Jesse Jhaj: Building Relationships with Patients as a Doctor or Healthcare Wo...saimasadaf14
 
mHealth Israel_Healthcare Finance and M&A- What Comes Next
mHealth Israel_Healthcare Finance and M&A- What Comes NextmHealth Israel_Healthcare Finance and M&A- What Comes Next
mHealth Israel_Healthcare Finance and M&A- What Comes NextLevi Shapiro
 
Chris Shade BS MEd MS LPC-Associate "Presume" (What Do I Do?)
Chris Shade BS MEd MS LPC-Associate "Presume" (What Do I Do?)Chris Shade BS MEd MS LPC-Associate "Presume" (What Do I Do?)
Chris Shade BS MEd MS LPC-Associate "Presume" (What Do I Do?)Chris Shade
 
Cell structure slideshare.pptx Unlocking the Secrets of Cells: Structure, Fun...
Cell structure slideshare.pptx Unlocking the Secrets of Cells: Structure, Fun...Cell structure slideshare.pptx Unlocking the Secrets of Cells: Structure, Fun...
Cell structure slideshare.pptx Unlocking the Secrets of Cells: Structure, Fun...ananyagirishbabu1
 
Best Way 30-Days Keto Meal Plan For Diet
Best Way 30-Days Keto Meal Plan For DietBest Way 30-Days Keto Meal Plan For Diet
Best Way 30-Days Keto Meal Plan For DietGunaPerumal1
 
Navigating Telehealth Innovations with PrudentRx
Navigating Telehealth Innovations with PrudentRxNavigating Telehealth Innovations with PrudentRx
Navigating Telehealth Innovations with PrudentRxPrudentRx Program
 
Breaking Down Oppositional Defiant Disorder Treatments
Breaking Down Oppositional Defiant Disorder TreatmentsBreaking Down Oppositional Defiant Disorder Treatments
Breaking Down Oppositional Defiant Disorder TreatmentsOppositional Defiant Disorder
 
INTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptx
INTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptxINTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptx
INTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptxAnushriSrivastav
 

Recently uploaded (20)

Mike Lowe’s cancer fight lowe strong shirt
Mike Lowe’s cancer fight lowe strong shirtMike Lowe’s cancer fight lowe strong shirt
Mike Lowe’s cancer fight lowe strong shirt
 
The Docs PPG - 30.01.2024.pptx..........
The Docs PPG - 30.01.2024.pptx..........The Docs PPG - 30.01.2024.pptx..........
The Docs PPG - 30.01.2024.pptx..........
 
Lactation Mraining Management Session-2-Comm-Building-Conf.ppt
Lactation Mraining Management  Session-2-Comm-Building-Conf.pptLactation Mraining Management  Session-2-Comm-Building-Conf.ppt
Lactation Mraining Management Session-2-Comm-Building-Conf.ppt
 
Digital Healthcare: The Future of Medical Consultations
Digital Healthcare: The Future of Medical ConsultationsDigital Healthcare: The Future of Medical Consultations
Digital Healthcare: The Future of Medical Consultations
 
Clinical pharmacy book by parthasarathi.pdf
Clinical pharmacy book by  parthasarathi.pdfClinical pharmacy book by  parthasarathi.pdf
Clinical pharmacy book by parthasarathi.pdf
 
Homeopathy Medicine for Diabetes_ Balancing Blood Sugar .pdf
Homeopathy Medicine for Diabetes_ Balancing Blood Sugar .pdfHomeopathy Medicine for Diabetes_ Balancing Blood Sugar .pdf
Homeopathy Medicine for Diabetes_ Balancing Blood Sugar .pdf
 
2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdf
2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdf2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdf
2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdf
 
Sugar Medicine_ Natural Homeopathy Remedies for Blood Sugar Management.pdf
Sugar Medicine_ Natural Homeopathy Remedies for Blood Sugar Management.pdfSugar Medicine_ Natural Homeopathy Remedies for Blood Sugar Management.pdf
Sugar Medicine_ Natural Homeopathy Remedies for Blood Sugar Management.pdf
 
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
Healthcare Market Overview, May 2024: Funding, Financing and M&A, from Oppenh...
 
LTM Session-8-Practices-that-assist-BF..ppt
LTM Session-8-Practices-that-assist-BF..pptLTM Session-8-Practices-that-assist-BF..ppt
LTM Session-8-Practices-that-assist-BF..ppt
 
Importance of Diet on Dental Health.docx
Importance of Diet on Dental Health.docxImportance of Diet on Dental Health.docx
Importance of Diet on Dental Health.docx
 
Jesse Jhaj: Building Relationships with Patients as a Doctor or Healthcare Wo...
Jesse Jhaj: Building Relationships with Patients as a Doctor or Healthcare Wo...Jesse Jhaj: Building Relationships with Patients as a Doctor or Healthcare Wo...
Jesse Jhaj: Building Relationships with Patients as a Doctor or Healthcare Wo...
 
mHealth Israel_Healthcare Finance and M&A- What Comes Next
mHealth Israel_Healthcare Finance and M&A- What Comes NextmHealth Israel_Healthcare Finance and M&A- What Comes Next
mHealth Israel_Healthcare Finance and M&A- What Comes Next
 
Session-10-Infants-with-Special-meeds.ppt
Session-10-Infants-with-Special-meeds.pptSession-10-Infants-with-Special-meeds.ppt
Session-10-Infants-with-Special-meeds.ppt
 
Chris Shade BS MEd MS LPC-Associate "Presume" (What Do I Do?)
Chris Shade BS MEd MS LPC-Associate "Presume" (What Do I Do?)Chris Shade BS MEd MS LPC-Associate "Presume" (What Do I Do?)
Chris Shade BS MEd MS LPC-Associate "Presume" (What Do I Do?)
 
Cell structure slideshare.pptx Unlocking the Secrets of Cells: Structure, Fun...
Cell structure slideshare.pptx Unlocking the Secrets of Cells: Structure, Fun...Cell structure slideshare.pptx Unlocking the Secrets of Cells: Structure, Fun...
Cell structure slideshare.pptx Unlocking the Secrets of Cells: Structure, Fun...
 
Best Way 30-Days Keto Meal Plan For Diet
Best Way 30-Days Keto Meal Plan For DietBest Way 30-Days Keto Meal Plan For Diet
Best Way 30-Days Keto Meal Plan For Diet
 
Navigating Telehealth Innovations with PrudentRx
Navigating Telehealth Innovations with PrudentRxNavigating Telehealth Innovations with PrudentRx
Navigating Telehealth Innovations with PrudentRx
 
Breaking Down Oppositional Defiant Disorder Treatments
Breaking Down Oppositional Defiant Disorder TreatmentsBreaking Down Oppositional Defiant Disorder Treatments
Breaking Down Oppositional Defiant Disorder Treatments
 
INTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptx
INTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptxINTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptx
INTERNATIONAL HEALTH AGENCIES BY ANUSHRI SRIVASTAV.pptx
 

2022 compliatric special webinar deep dive into good faith estimate

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