Which Patients Should Receive a Good Faith Estimate?
We have been getting questions about which patients should receive good faith estimates (GFE’s). This week we provide you with information on who should receive GFE’s and when. Watch the video to learn more!
Link mentioned in today’s video
Good Faith Estimates – No Surprises Act
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Transcript:
Last week, we talked about good faith estimates and their applicability to your practice and why they are required by federal law that you provide them. One of the next really big questions that we get all the time is, so you mean, I have to give a good faith estimate in this specific format to every single one of my patients that comes in? No, that’s not how this works. In fact, they really addressed in the No Surprises Act that passed a very specific that well in the rules, especially a very specific subset of patients, and those are those patients who are not filing insurance, but instead are self-pay patients. In fact, that’s how the rule refers to them as self-pay patients. And so we’re going to spend a little bit of time and make sure you understand who is a self-pay patient because that is the subset of people who actually you’re required to provide a good faith estimate to or a GFE.
So here’s how this works. A self-pay patient is someone who is uninsured, they do not have health insurance. All right, that’s the first category, those are easy to identify. Right? That’s, that’s pretty simple. The next subset are those that have insurance but are choosing to have you not bill their insurance. Okay. And then the third subset of people that this would apply to are those who have health insurance, but the specific services or items that you’re providing or anticipate providing for them are not covered by their insurance, and you know, this. Now, of course, I’m not talking about when you get denials at a later date. That’s not the issue. Really, this would be more along the lines of let’s talk Medicare. I mean, because that’s a simple one, right? Medicare, we know, currently does not pay for examinations, modalities, physical therapies, they only pay for that spinal adjustment, that spinal manipulation. And so it’s very important to know that we know that those other services are not covered. So Medicare patients who are receiving any of those non-covered items or services by Medicare, they would be entitled to receive a GFE, a good faith estimate.
Now, this is really important to understand your participation status with that insurance company doesn’t matter. In fact, neither does it matter if you’re even going to bill the insurance company. The key is if they have insurance on that second point that I mentioned earlier, if they have insurance, and they are going to bill the insurance, you’re not if you’re out of network, and you choose to collect from the patient, have them provide that bill. In those cases, because they’re going to be submitting it to their to their own insurance on their own. They are not a self-pay patient, even though they paid you that doesn’t matter according to the law, according to the rules that are carved out. As long as it’s going to be billed to insurance then at that stage. They are not self-pay patients. That’s really important.
Other key clarification points, high deductibles, right, we get this question a lot. So what if somebody has a high deductible? How does this work for them? Well, those that have high deductibles, they’re not self-pay patient if you’re billing or they are billing their health insurance, right? So even if you are or they are billing, their health insurances, their health insurance for the items and services that you’re providing in your practice, they’re not self-pay. However, if their high deductible plan, and they’re like, don’t even bother sending, I’m never going to hit my deductible. Don’t bother sending it off. In those particular cases, and they’re telling you don’t bill on my insurance, or I’m not going to be billing if you happen to be out of network and they bill on their own. In either of those cases, if they’re not billing their insurance, then they are a self-pay patient. So understand that good faith estimates currently are only required to be provided for self-pay patients, as I just discussed. We have a whole lot more information online, you can always jump out to ilchiro.org/gfe that’s Good Faith Estimate G F E. So ilchiro.org/gfe and you can get all of this information it’s carved out, as well as steps what you can do, there’s downloadable forms, everything that you’re going to need to be able to fulfill the requirements under the No Surprises Act, or at least this portion.
If you want to know is this really applicable to our practice? We covered that in last week’s video, I really strongly encourage you to check that out. Again, we’re going to cover a few more things in the coming weeks that are important for you to understand in regard to good faith estimates and the No Surprises Act. Next week, we’re going to talk about what really are good faith estimates. What are they? Why is this important? Why is this any different than what I’m already giving him if you happen to be doing a financial disclosure with a patient there’s more specificity we’ll catch that we’ll talk about that next week catch you then.
