Late Night With Chip & Paulie (Episode 5)

Late_Night_E5_Slides.pdf (2.8 MB)

Great webinar! I was in and out of it so maybe this was answered already. It sounds like if we bill the insco, expecting no payment bc OON, then the GFE is not needed? Is this correct?

Correct…the No Surprises Act only applies to “expected” self-pay patients.

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Question on timing for GFEs, specifically sending a GFE within 3 business days of scheduling the appointment (if 10+ days in advance): If we have a self-pay patient scheduling their well visit for next year, do we send a GFE within 3 days of the appointment being scheduled? Wouldn’t it make more sense to send a GFE the following year (within 3 days of their appointment) since we update our fee schedule yearly?

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This is an excellent point. However, the regulations clearly didn’t expect you’d schedule something so far in advance (and be self pay).

The requirement remains that, in this circumstance, you’d provide the GFE three days after scheduling the appointment (i.e. 362 days in advance). There is no requirement for “updating” it closer-to-time, and in fact, if you updated/amended your GFE and your prices went up, you would probably be in violation of the GFE.

You still have $400 grace amount for your prices to go up in a year, which for most primary care services is probably appropriate. Let’s hope new vaccines not covered by the VFC program for adolescents don’t come out in 2022 :slight_smile:

I’ve studied it more carefully… the law does not apply to care from OON providers at OON facilities. As an independent practice we are the facility and provider, so if an OON patient wants to see us, then we don’t need to give them the notice and consent from, right? We can bill the ins and get denied for OON and and bill the patient. I mean, we wouldn’t bill them the full charge anyway, but at least the paperwork is not required?

It doesn’t happen that often, but there are times when a patient had selected an network we’re not in, and they want to still see us for a sick visit for the cash price. It seems the NSA wouldn’t apply in these cases.

The GFE part of the law does apply to OON providers/facilities if you treat them as self pay. But if you file a claim for an OON patient, then that is correct.

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Because she is the Hardest Working Doctor In Show Business, @SKB grabbed all of the questions from the chat the other night and provided a response to each, which I share below. As always, we owe her a debt of gratitude. Do something nice for someone today.

Question/Comment SKB Response
I worry about families refusing a lot of well check components Our proposed all-inclusive model actually makes that less likely. By quoting a flat fee for a 9939x, and indicating that there will be no additional charge for screens, hemoglobin, etc., families are more likely to opt in to the whole bundle as opposed to line-item vetoing.
If they have one of those Christian ministries non ins ins - how do we look at their responsibility? Is it the entire thing? If you bill the health share plan directly “to see what they pay,” one could argue that the GFE doesn’t apply to you. If you charge them cash up front and let them submit for cost-sharing, certainly the GFE applies for all services on the day of appointment.
Until 2023 when you have to provide it for commercial also GFEs must be provided now for commercial insurances that your practice does not send a claim to.
What if they are insured when they make the appointment, but then become uninsured (and presumably you find out?) Do we have to do this at that point, or does the original scheduling govern? There are no regulatory requirements that discuss a patient’s insured status changing between when the GFE is generated (within a day or two of scheduling) and the actual appointment. Practically, you cannot be expected to check every insured patient to see if they become uninsured over a period of 2 months while waiting for an appointment. I might argue that if a patient calls you to notify you before the appointment that they had insurance, but now they don’t, that that might trigger the need for a GFE for any future appointments on the books. Chip: Perhaps we should think about what happens with automated eligibility checks that might, for example, tell us that someone is no longer ensured a week+ before the appointment.
Is this for newborns as well that are not connected to insurance within 30 days of booking It depends on how your practice handles these kinds of visits. If you expect patients to pay on the DOS, and you’ll refund their money if they later produce a backdated insurance and you send a claim, then you must provide a GFE. If you do not treat these patients as self pay because you are holding their claim until they are added, you are considering them insured.
So it’s the provider’s responsibility to know if we’re in network or not then? Sometimes there’s a new network and it’s not clear whether we’re in it or not. The GFE portion of the NSA isn’t about being in network vs “out of network,” it’s about sending a claim vs not. If a patient shows up with an unfamiliar insurance card, do you typically agree to send a claim to “see what it pays,” or do you reject it out of hand and require the family pay cash to be seen? That said – If you are collecting patient insurance at the time the appointment is scheduled, you can validate it on the fly using 270/271 and see whether your practice is in network or not. Chip: I’m also going to say…yeah, you should know if a patient is in-network or not as a rule! Get your eligibility work flow on point.
English and Spanish? Or only English? 149.610 says the GFE should be “Made available in accessible formats, and in the language(s) spoken by individual(s) considering or scheduling items or services with such convening provider or convening facility…” which presumably is English, Spanish, or another language.
How do you estimate reflex tests? You can use the “reasonably expected” language to decide whether or not to include a particular charge based on its frequency. For reflex tests that frequently go on to the end point, you can quote the entire price (the pre-test and the test). For reflex tests that rarely get reflexed, you can quote the pre-test price only.
If you send patient to quest with lab order and quest draws lab. Do they do gfe? If you provide the patient a lab order and they leave your facility to go to Quest/Labcorp, you are not the convening provider for Quest/Labcorp and you need not provide those lab estimates in your GFE.
What about sending Covid swab to Quest for PCR? In 2023, you will be required to provide these anticipated costs on your practice’s GFE form, provided you are the convening provider (however, if you give the patient an order where they can have the specimen collected at any facility, and they choose Quest/LabCorp/etc, then you are no longer the convening provider and you need not supply a GFE for the lab charges.)
So strep culture sent out after a negative screen will need a GFE? Yes – if a strep culture is an “item or service reasonably expected to be furnished at the time the good faith estimate is issued.” If you order back up strep cultures on less than 5% of your patients whom you see as EST SICK, and <1% of patients who are booked as EST WELL, then you could argue that these frequencies are too low to be “reasonably expected to be furnished.”
What about radiology if we order it? MRI/CT/Xray/VCUG etc MRI and VCUG are not walk-in tests; they must be scheduled separately by the imaging facility, so those would never be part of your GFE. If a CT and Xray can be “reasonably expected items or services reasonably expected to be furnished at the time the good faith estimate is issued,” then yes, you would need to put those services from co-providers on your GFE.
What if the visit is for a specific reason and the patient/parent add another issue they were not booked for are we on the hook for the GFE? One of the required disclaimers in the GFE is, “A disclaimer that informs the uninsured (or self-pay) individual that the information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual items, services, or charges may differ from the good faith estimate.”
Newborn feeding problems MD notes latching issues and then see tongue tie so does frenulectomy - basic charge just hit $600 due to surgery code for frenulectomy. Cant be known until the patient is in the exam room Multiple ways to solve this problem. You can create a GFE for NEWBORN VISIT with a charge for the office visit and a separate line item for the frenulectomy. Alternatively, if you know from data that 10% of newborns will need a frenulectomy, then you can distribute the cost of your frenulectomy charge by 10% into your flat rate.
likely charge $250 and refuse to give vaccines if no insurance. Safe bet Refusing to give vaccines to uninsured patients seems unethical (and also violates the terms of the VFC program, although I presume you don’t participate.) Add a contigent estimate to your GFE that each vaccine given will be $150 (or whatever your weighted average is).
For OON patients who want to see us and pay cash, so if we send the claim to insco, then the GFE is not needed? Yes, because you’re not treating them as effectively self pay if you are sending a claim to their insurance.
If you quote everyone $100 for sick and $200 for well, you should be safe. In terms of picking a price and sticking to it, this wisdom is generally sound!
If you participate in VFC, vaccines are no charge for self pay That’s true, as long as patients are 18 yo or under.
Suzanne - do you have an SQL we can use for this? Yes, for OP practices. See Google Colab to create your own violin plots of fees by appointment type.
Better to estimate $183, and surprise many with actual charges of $155? Yes. There is no penalty for sending an actual bill that’s less than the up-front estimate.
Do you recommend charging 80% because you aren’t sending a claim? Or - charge 100% because many of these patients will be on Medicaid and sometimes they will back pay. I don’t know why you would charge 80% because you’re not sending a claim - particularly if you are discussing a patient population who will eventually need a claim sent. Keep it simple - stick to one charge.
so you wouldn’t have to itemize the charges by CPT code if you do one price for all well visits? If you say, “My price for a 9939x visit is $X, and there is no additional charge for associated Bright Futures services even if they have separately billable CPTs,” you’ve effectively done that.
To the person who has insurance and decide they want to pay cash for a WV, are we able to charge the price for immunizations that we would charge their insurance? They wouldn’t qualify for VFC since they have insurance Yes.
Do we need to get confirmation that the family received the estimate? Agrees to it? No. That’s not part of the GFE. We presume that you already have a general agreement (signed at the first visit) in which families timely agree to pay the amounts you bill.
Are we allowed to charge self pay patients less than other people? I thought we weren’t allowed to charge patients less than we bill insurance? Yes. You’re referring to a “most favored nation” clause in insurance contracts, which are now illegal in many US states and have been quietly removed from many other insurance contracts. If you still have a MFN clause in an insurance contract, share that information with your state’s Pediatric Council or state insurance commissioner.
Do we quote the price before or after prompt-pay discount (effectively self-pay discount)? For simplicity’s sake, I’d quote the “Before” price and then add (possibly to your list of disclaimers at the bottom), “We will discount these fees by X% if you pay in full at check-in,” or whatever your prompt pay policy is.
i’m also interested in the question about what language GFE must be given in? English? Spanish? Marshallese? 149.610 says the GFE should be “Made available in accessible formats, and in the language(s) spoken by individual(s) considering or scheduling items or services with such convening provider or convening facility…” which presumably is English, Spanish, or another language.
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chip your graph of PCC visit types was very edifying for my, but I wonder if you have a way to break down well visits by age? can you create a time-line for newborn visits?

Thank you Dr. Berman. You are a hero!

I can, sure - but I’m curious to understand what you are looking for? A change in the birth rate?

yes, in my area it’s dwindled over last 2 yrs to the point where some OB services closed.

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btw how does new Federal law help people who go to ER ? ER under no obligation as there was no prior appt, and if they’re very sick or injured, a patient is still stuck.

Ohhh, there are LOTS of obligations now on hospitals (including outpatient emergency departments). In fact, the bulk of the No Surprises Act has to do with how hospitals treat self-pay and out-of-network patients. We alluded to this on our second slide (“Additional rules apply if…”) but we didn’t go into this given time limits.

I was wondering about the delivery of the GFE. The GFE has patient-specific info, so it should be sent via patient portal. But we know that a lot of patient don’t check the portal. Should we send it straight to their email, which would be not HIPAA compliant? Does the law state anything specific about the delivery?

Your second question first: The law states you can furnish the GFE “paper or electronically” but doesn’t unpack all the different electronic modalities.

Here’s what HHS has to say about communicating with patients by email: Does the HIPAA Privacy Rule permit health care providers to use e-mail to discuss health issues and treatment with their patients? |

It’s perfectly permissible to communicate with patients by email, provided you use encryption (and common sense), and you respect the wishes of a patient who says “Please don’t send my GFE by email.”

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Please check my latest blog entry about this topic:

Exec summary: I don’t think people have slowed with making babies. I think hospitals are closing OB/birthing centers regardless.