What PTs, OTs, and SLPs Need to Know About the No Surprises Act

Extra, extra! Read all about it! Some new legislation is taking effect in 2022—and it affects PTs, OTs, and SLPs who provide cash-pay services to uninsured or self-pay patients. Using this resource from the Centers for Medicare and Medicaid Services and this resource from the APTA, we’ve put together an FAQ-style explainer to help you navigate everything you need to know about the No Surprises Act. Read on for more details!

What is the No Surprises Act? 

The Real Life Scenario

Okay, picture this. You’re having a medical emergency—your appendix burst—and you need to rush to the hospital to get surgery as quickly as possible. Your family doesn’t think they can drive you to the hospital fast enough, so they call an ambulance. That ambulance takes you to an ER, you go into surgery, and you emerge hours later with a clean bill of health. 

But that’s not the only bill you get.

Turns out that while the hospital was totally in network, none of the docs (or the ambulance for that matter) were in-network for your insurance plan, and you’re stuck with a mondo out-of-network bill that you weren’t expecting.

The goal of the No Surprises Act is to stop those scenarios in their tracks. 

The Cut and Dry Legislative Info

Per the APTA, the No Surprises Act was a bill passed in 2020 that was designed to protect patients from surprise medical bills (i.e., balance billing) that occur “most often when the patient couldn’t choose their provider, such as in an emergency.” As a result, a majority of the mandates in the act apply to emergency services, emergency travel, and out-of-network providers at in-network facilities (e.g., anesthesiologists, surgeons, radiologists).

What part of the No Surprises Act applies to PTs, OTs, and SLPs? 

While most of the No Surprises Act applies to providers and facilities who furnish emergency services, there is one mandate called the Good Faith Estimate that applies to everyone. Or, as CMS so deftly put it, “No specific specialties, facility types, or sites of service are exempt from this [the good faith estimate] requirement.”

Then what are Good Faith Estimates? 

Good Faith Estimates (GFEs) are basically what they sound like; they are estimates provided in good faith (i.e., they are as accurate as possible) to uninsured or cash-pay patients for services they have yet to receive. This tells patients how much they can expect to pay for a service beforehand—thus eliminating surprise bills. 

Are there any unusual rules about how I need to provide these Good Faith Estimates?

Good question. Yes! There are lots of very specific rules surrounding how providers need to distribute Good Faith Estimates. Here they are in a bulleted list: 

On top of all that, GFEs must be provided in one of the following timeframes: 

And if you need to update a good faith estimate that’s already been given to a patient, “provide a new good faith estimate no later than one business day before the scheduled appointment.”

What exactly goes on a Good Faith Estimate?

Before we list out the very long list of very specific information that must be included in a GFE, we encourage you to check out this Good Faith Estimate template courtesy of CMS. It should help you tick off the requisite compliance boxes.

But without further ado, a GFE should contain the following information: 

A word of advice: Use that GFE template provided by CMS. 

What happens if I don’t follow all of these rules?

If you don’t follow all of the GFE rules, patients may be able to dispute their bills and avoid paying them. But more importantly, per this legal news source, “HHS may impose a corrective action plan and/or civil monetary penalties of up to $10,000 per violation.”

When does the No Surprises Act take effect—and how should I prepare for this? 

The No Surprises Act—and the corresponding Good Faith Estimate requirement—took effect on January 1, 2022. So, if you’re not already providing these estimates to your uninsured and self-pay patients, it’s time to start. 

Will I ever need to provide Good Faith Estimates to insured patients?

Maybe—though it’s tough to say for sure. The Department of Health and Human Services (HHS) “has not yet issued rulemaking related to the provision of GFEs for individuals who are enrolled in a plan or coverage and are seeking to have a claim submitted to their plan or coverage.” All this means is that the HHS will not act on providers who don’t provide GFEs to insured patients—for now.

Now that’s what we call big news! Credit where credit is due to these wonderful resources from CMS and the APTA—check ‘em out if you’ve got a chance!

Got any more questions about Good Faith Estimates? Drop ‘em below and we’ll do our best to find you an answer.