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No Surprises Act Implementation

The “No Surprises Act” (the Act), which allows for patient financial protections that impact health plans, physicians, and facilities, will apply to psychiatrists in certain circumstances. Psychiatrists working in group practices or larger organizational settings and facilities will likely receive direction from their compliance department or lawyers on how to satisfy these new requirements. The following information is geared toward solo/small group practices.

The most significant change for psychiatrists providing care in the outpatient setting is a new requirement to provide a good faith estimate (GFE). Beginning January 1, 2022, psychiatrists and other health care providers will be required to give new and established patients who are uninsured, or self-pay, or patients who are shopping for care, a good faith estimate of costs for services that they provide.

The following is a summary of the key requirements of the good faith estimate (GFE) along with links to templates.  You can find more information in our responses to questions (.pdf) sent by APA members to the APA’s Practice Management HelpLine, including a sample GFE (.pdf). If you have additional questions, please send them to [email protected]. We will update this information as we learn more.

The Good Faith Estimate

The Centers for Medicare and Medicaid Services (CMS) have provided instructions and a sample good faith estimate template (.pdf). It must contain the following information in clear and understandable language:

  • The patient’s name and date of birth;
  • A description of the primary service (i.e., E/M, psychotherapy) being furnished to the patient (and if applicable, the date (or date range if recurring) the primary service is scheduled);
  • An itemized list of services that are “reasonably expected” to be furnished (this could be what is captured in your standard fee schedule depending on patient need);
  • Applicable diagnosis codes (if established; otherwise create standard language such as “TBD pending evaluation for MH/SUD”), expected service codes, and expected charges associated with each listed item or service (this may already be captured in your fee schedule);
  • The name, National Provider Identifier (NPI), and Tax Identification Number (TIN) of each provider or facility represented in the good faith estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished. (Solo psychiatrists would list their name, NPI/TIN and address; APA recommends using a business TIN rather than your SSN;
  • A list of services that the provider or convening facility (the provider or facility that handles the scheduling of the service) anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service (this may be less applicable in psychiatry; for services that fall outside the routine care); 
  • A disclaimer that there may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate;
  • A disclaimer that the information provided in the good faith estimate is only an estimate and that actual items, services, or charges may differ from the good faith estimate; and
  • A disclaimer that informs the patient of their right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the good faith estimate. This should include instructions for where the patient can find information about how to initiate the dispute resolution process, as well as a statement that the initiation of a patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to the patient; and
  • A disclaimer that the good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the services from any of the providers or facilities identified in the good faith estimate.

The required disclaimers are included in the CMS template cited above.  Make a good faith effort to provide all the information.

“Provider” is defined broadly to include any health care provider who is acting within the scope of the provider’s license or certification under applicable state law. Psychiatrists meet that definition.

The definition of “items and services” for which the good faith estimate must be provided is also broadly defined to encompass “all encounters, procedures, medical tests, … provided or assessed in connection with the provision of health care.” Services related to mental health and substance use disorders (E/M services, psychotherapy, etc.) are specifically included.

At the present time, the requirement for a good faith estimate applies to these categories of patients:

  1. Patients who do NOT have health insurance of any kind, ( i.e., commercial insurance, HMOs, union health plans or government health plans.)
  2. Patients who DO have health insurance that would pay for all or part of your treatment, but who DECLINE to use their insurance for the cost of your treatment.
  3. Patients who are shopping for care.

For now, federal law requires that you provide ONLY these patients (in these three categories) with a written notice regarding the cost of expected services.

Under the new rule, psychiatrists and other providers must take the following steps for their uninsured or self-pay patients (Note that the rules and templates are written to address care provided by a range of clinicians and are not specific to psychiatry):

  1. Ask if the patient has any kind of health insurance coverage (including government insurance programs like Medicare, Medicaid, or Tricare), and, if so, whether the patient intends to submit a claim to that insurance for the service. If patients are covered by insurance and intend to submit a claim then they are not considered an uninsured or self-pay patient.
  2. Inform all uninsured and self-pay patients through a prominently displayed notice (office, website) that a good faith estimate of expected charges is
    • available in a written document that is clear, understandable; and
    • will be orally provided when the service is scheduled or when the patient asks about costs; and
    • available in accessible formats, and in the language(s) spoken by the patient.
    While use of CMS’ model GFE (.pdf) notice is not required, CMS views its use as making a good faith effort to comply with the new regulations.
  3. Provide a good faith estimate of expected charges for a scheduled requested service, including services that are reasonably expected to be provided in conjunction with such scheduled or requested service. For routine care this could be done once a year (i.e., annually to coincide with changes in fees):
    • If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling; or
    • If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling; or
    • If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request. A new good faith estimate must be provided, within the specified timeframes if the patient reschedules the requested service.

If any information provided in the estimate changes, a new good faith estimate must be provided no later than 1 business day before the scheduled care. Also, if there is a change in the expected provider less than one business day before the scheduled care, the replacement provider must accept the original good faith estimate as their expected charges.

The good faith estimate is a notification of expected charges for a scheduled or requested service. The “expected charge” for a service is either:

  • the cash pay rate or rate established by a provider for an uninsured (or self-pay) patient, reflecting any discounts for such individuals; or
  • the amount the provider would expect to charge if the provider intended to bill a health care plan directly for such service.

You can attach your fee schedule to the estimate.

 

The information provided in the good faith estimate is only an estimate, and the actual items, services, or charges may differ from what is included in the good faith estimate. However, uninsured or self-pay individuals may challenge a bill from a provider through a new patient-provider dispute resolution process if the billed charges substantially exceed the expected charges in the good faith estimate. Substantially exceeds means an amount that is at least $400 more than the expected charges listed on the good faith estimate for a specific provider.

There is no penalty if you overestimate the costs. We recommend that if in doubt, you overestimate expected charges.

The Centers for Medicare and Medicaid Services (CMS) have provided instructions and a sample good faith estimate template (.pdf). It must contain the following information in clear and understandable language:

  • The patient’s name and date of birth;
  • A description of the primary service (i.e., E/M, psychotherapy) being furnished to the patient (and if applicable, the date (or date range if recurring) the primary service is scheduled);
  • An itemized list of services that are “reasonably expected” to be furnished (this could be what is captured in your standard fee schedule depending on patient need);
  • Applicable diagnosis codes (if established; otherwise create standard language such as “TBD pending evaluation for MH/SUD”), expected service codes, and expected charges associated with each listed item or service (this may already be captured in your fee schedule);
  • The name, National Provider Identifier (NPI), and Tax Identification Number (TIN) of each provider or facility represented in the good faith estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished. (Solo psychiatrists would list their name, NPI/TIN and address; APA recommends using a business TIN rather than your SSN;
  • A list of services that the provider or convening facility (the provider or facility that handles the scheduling of the service) anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service (this may be less applicable in psychiatry; for services that fall outside the routine care); 
  • A disclaimer that there may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate;
  • A disclaimer that the information provided in the good faith estimate is only an estimate and that actual items, services, or charges may differ from the good faith estimate; and
  • A disclaimer that informs the patient of their right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the good faith estimate. This should include instructions for where the patient can find information about how to initiate the dispute resolution process, as well as a statement that the initiation of a patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to the patient; and
  • A disclaimer that the good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the services from any of the providers or facilities identified in the good faith estimate.

The required disclaimers are included in the CMS template cited above.  Make a good faith effort to provide all the information.

Yes, the rule makes no distinction between current and future patients.

You should provide this estimate to all of your current patients in the two groups listed above on (or about) January 1, 2022. You can use email on the 1st of the year. Otherwise, we suggest mailing the notice to all current patients (in the three categories).

The law also requires you to provide notice to all new patients (in the three categories) when they start treatment on or about January 1, 2022. The law also requires that all of these patients (in the three categories) receive a new notice every year or if your fees change. We suggest for the sake of simplicity and to avoid confusion, that you provide all patients (in the three categories) with a notice on (or about) January 1st of each year (or to coincide with any scheduled rate increase) including new patients who started treatment during the past year.

The Prohibition Against Surprise Billing for Emergency Care

NSA also aims to address situations in which patients receive surprise medical bills when they inadvertently or unknowingly receive care from an out-of-network provider. These new protections for patients do not apply in physician offices but may apply in other settings:

  • The Act bans surprise billing for emergency services. Emergency services, even if they’re provided out of network, must be covered at an in-network rate without requiring prior authorization.
  • The Act bans balance billing and out-of-network cost-sharing (such as out-of-network coinsurance or copayments) for emergency and certain non-emergency pre-scheduled care. In these situations, the consumer’s cost for the service cannot be higher than if these services were provided by an in-network provider, and any coinsurance or deductible must be based on in-network provider rates.

Read on for answers to FAQs that apply to practicing psychiatrists who treat patients in facilities.

Under the NSA, the definition of emergency services includes care provided in emergency departments of hospitals and in independent, freestanding emergency departments. Emergency care is not considered care provided in a physician’s office, such as the office of a psychiatrist.

Under the NSA, the definition of non-emergency care includes care provided in hospitals, hospital outpatient departments, critical-access hospitals and ambulatory surgical centers. Non-emergency care, for the purposes of this new law and corresponding regulations, does not include care provided in a physician’s office, such as the office of a psychiatrist.

They go into effect on Jan. 1, 2022.

These rules are targeted foremost at facilities such as hospitals. Psychiatrists providing care at facilities that provide emergency or non-emergency care, as delineated above, could be impacted by these new rules. If you are in such a setting, you should consult with your facility or clinic’s compliance officer or attorney about your personal obligations under this new regulation.

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