The Good Faith Estimate (GFE) is a document providing price transparency in American healthcare. It functions as an advance notification of expected charges for a scheduled medical service or item. Federal legislation requires this estimate to protect consumers from financial surprises related to their medical care. While insured patients typically do not receive a GFE, specific circumstances allow them to qualify.
The Origin of the Good Faith Estimate
The requirement for the Good Faith Estimate was established by the No Surprises Act, a federal law effective January 1, 2022. This legislation primarily shields consumers from unexpected medical bills, especially those arising from out-of-network services. The GFE provision specifically increases cost transparency for patients who are not using their insurance. Providers are mandated to furnish this advance estimate to certain individuals. The goal of this rule is to empower patients with knowledge of their financial responsibility before they receive non-emergency care.
When Insured Patients Qualify for a GFE
Insured patients planning to use their health benefits for a covered service typically do not receive a Good Faith Estimate directly from the provider. When a patient submits a claim, the provider must send the estimated charge information to the insurance company. The insurer then uses this information to create an Advanced Explanation of Benefits (Advanced EOB) for the patient. The Advanced EOB outlines the expected cost-sharing responsibilities based on the patient’s plan.
An insured patient is entitled to receive a GFE directly from the provider only if they explicitly choose not to use their insurance benefits for a service. This means electing to be a “self-pay” patient for that specific item or service, despite having coverage. A patient might choose the self-pay route if the provider’s cash price is lower than their deductible. They may also choose this route if they prefer to keep the service confidential from their insurer. In this scenario, the provider must treat the insured patient the same as an uninsured individual under GFE rules.
Another circumstance where an insured patient qualifies for a GFE is when the service is explicitly not covered by their insurance plan. This includes services like certain cosmetic procedures, experimental treatments, or services exceeding the plan’s annual limits. If the service is not covered and the patient is responsible for the full amount, they are considered a self-pay individual for that service. Providers must inquire about a patient’s insurance status and their intent to use coverage when scheduling a service.
GFE Requirements for Uninsured and Self-Pay Patients
The primary application of the GFE rule protects patients who are uninsured or those who choose to self-pay. This includes insured patients who opt out of submitting a claim. Providers must furnish this estimate for any non-emergency item or service. The estimate must be provided when the service is scheduled or upon the patient’s request.
The timing for delivering the GFE depends on the scheduling date.
Timing Requirements
If the service is scheduled at least 10 business days out, the estimate must be given within three business days of scheduling.
If the service is scheduled between three and nine business days in advance, the estimate must be provided within one business day.
A GFE is generally not required for services scheduled less than three business days in advance.
The Good Faith Estimate must be a comprehensive, itemized list of all expected charges. This includes the primary service and any other items reasonably expected to be provided in conjunction with that care, such as medical tests or facility fees. The estimate must clearly include the diagnosis codes, service codes, and expected charges for each item. The provider who schedules the primary service, known as the “convening provider,” is responsible for collecting and including estimates from any co-providers or co-facilities involved in the patient’s care.
Recourse When the Final Bill Exceeds the Estimate
The Good Faith Estimate includes a consumer protection mechanism to hold providers accountable for the estimate’s accuracy. If the final bill is substantially higher than the amount listed on the GFE, the patient has the right to dispute the charges. The dispute threshold is met if billed charges are $400 or more above the total estimated amount.
This process is called the Patient-Provider Dispute Resolution (PPDR) and is administered by entities selected by the Department of Health and Human Services (HHS). The patient must initiate the challenge within 120 calendar days after receiving the disputed bill. While the PPDR process is underway, the provider or facility is prohibited from pursuing collection efforts against the patient. The dispute resolution entity evaluates the claim and determines the amount the patient owes. If the provider cannot justify the overage with credible information, the patient may only pay the estimated amount.