January 21, 2022
The federal regulation called the No Surprises Act (P.L. 116-260) went into effect January 1, 2022. ASHA provided comments [PDF] on the No Surprises Act before the regulation was finalized.
Congress enacted the No Surprises Act (the Act) to protect patients from costly, unexpected medical bills. The regulation applies to all health care providers, which the Centers for Medicare & Medicaid Services (CMS) defines as “a physician or other health care provider who is acting within the scope of practice of that provider’s license or certification under the applicable state law.” This means that the new regulation applies to both audiology and speech-language pathology providers. However, the provision only applies to patients without insurance who are self-paying or insurance where the provider is considered out-of-network.
The regulation includes a provision for Good Faith Estimates, which informs patients of the cost of care they will be receiving before their appointment. This is the portion of the regulation that will impact audiology and speech-language pathology the most. Beginning January 1, 2022, audiologists and speech-language pathologists (SLP) are required by law to provide a Good Faith Estimate to every new and established patient who is either seeking treatment as a self-pay patient or is considered out-of-network with you as a provider. A Good Faith Estimate is the best judgment of the cost of care a provider plans to offer to the patient across the episode of care.
To protect patients, the law also requires that the provider’s Good Faith Estimate must be within $400 of the actual charge(s) to the individual for the service(s) you provided. The threshold for “substantially in excess” means that the estimate exceeded the expected charges by at least $400 of what was provided in the Good Faith Estimate. If this occurs, a patient who is self-paying or not using insurance has the right to challenge the bill through a dispute resolution process. The “substantially in excess” provision applies to the per visit cost as opposed to the total plan of care cost. Best practices for your Good Faith Estimate would be to list your price per visit for the evaluation and your price per visit for each of the individual’s follow-up visits. Share the expected range of follow-up visits and consider adding a total expected cost range.
Many providers develop a Good Faith Estimate form for self-paying patients and those where you, as a provider, are considered out-of-network. To comply with the new law, you must have the patient sign the Good Faith Estimate form and maintain the signed document in the patient’s medical record.
See ASHA’s webpage on Good Faith Estimate Templates for Audiologists and Speech-Language Pathologists.
Patients who do not have insurance or who are not using their health insurance to cover visits are required to receive a notice of their right to request a Good Faith Estimate at any time. CMS has a sample [PDF] that you may use for reference.
Currently, patients who have Medicare, Medicaid, or any other federal health care program, are exempt from this process.
The law has specific guidelines for when a patient must receive a Good Faith Estimate. These are largely intended for scheduled in-patient procedures but can be applied to planned outpatient services as well.
The Good Faith Estimate must be provided in writing, signed by the patient, and included as part of the patient’s medical record. If it is being provided electronically, the patient must have the ability to print a hard copy, and a signed copy must still be included in the medical chart. A verbal explanation with no documentation is not a compliant format.
Audiologists and SLPs may find it difficult to know in advance how many visits will be needed and the full nature of those visits. In these instances, it may be better to offer a range of potential costs. When doing so, your Good Faith Estimate document must meet two additional requirements:
Here is an example of language that could be used by audiologists and SLPs in these circumstances.
It is estimated that you may need between [insert range of visits] this year. At [$xxx per session], we estimate your total cost of care to be between $[ insert range of total cost here].*
*At this time, CMS does not explicitly state the need for a total cost at the end of this statement. You may include one if you choose but it is not required. ASHA is seeking additional clarification from CMS on this issue and will provide updated guidance if needed.
The Act prohibits balance billing for emergency services. For non-emergency care (like audiology and speech therapy services), balance billing is only allowed if the patient has been given notice and provided specific consent. For most audiology and speech-language pathology services, a Good Faith Estimate should be available by reviewing the fee schedule with the specific payer since these are not typically emergency visits.
Contact Jacob Manthey, ASHA’s director of health policy for private health plans and reimbursement, at email@example.com.