The Good Faith Estimate (GFE) is a mandated tool for financial transparency, designed to give patients an expected cost before they receive medical services. This document aims to bring clarity to the often-opaque pricing of medical items and services, safeguarding specific consumers against unexpected high bills.
Defining the Good Faith Estimate
The Good Faith Estimate (GFE) is a formal notification outlining the anticipated charges for a scheduled or requested medical item or service. Its existence is a direct requirement of the No Surprises Act (NSA), a federal law enacted to protect patients from unexpected medical bills. The GFE requirement applies to uninsured individuals and those who choose to pay for their care directly, known as self-pay patients.
A patient is considered “uninsured” if they are not enrolled in a health plan, while a patient with insurance is considered “self-pay” if they opt not to submit a claim to their insurer for a particular service. Providers are required to accurately and comprehensively forecast the total cost of care for these individuals. This estimate must include all expected charges for the primary service and any other items or services reasonably anticipated to be provided in conjunction with it.
When You Should Receive an Estimate
The requirement to issue a Good Faith Estimate is triggered when an uninsured or self-pay patient schedules a service or requests an estimate. Providers must proactively ask patients about their insurance status at the time of scheduling to determine if a GFE is necessary. The timing for delivery depends on how far in advance the service is scheduled.
If a patient schedules a service at least 10 business days before the appointment, the provider must furnish the GFE no later than three business days after scheduling. For services scheduled between three and nine business days in advance, the estimate must be provided no later than one business day after scheduling. Patients also have the right to request an estimate without scheduling a service, in which case the provider must supply the GFE within three business days of the request.
What Information the Estimate Must Include
The Good Faith Estimate must be a comprehensive, itemized document detailing the anticipated costs of care. The document must clearly identify the patient by name and date of birth, along with a description of the primary service in clear language. It must include the expected charges for each item or service, reflecting any discounts for uninsured or self-pay individuals.
The GFE must also include several specific elements:
- Applicable diagnosis codes and expected service codes, such as Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, alongside the expected charges for each listed service.
- The name, National Provider Identifier (NPI), and Tax Identification Number (TIN) for the convening provider and any co-providers or co-facilities expected to be involved in the care.
- A disclaimer stating that the GFE is only an estimate and not a contract.
- Information informing the patient of their right to initiate a dispute resolution process if the final bill exceeds the estimate by a specific threshold.
The Patient-Provider Dispute Resolution Process
The Patient-Provider Dispute Resolution (PDR) process provides recourse if a patient receives a final bill that is significantly higher than the expected charges on the GFE. This process can be initiated if the total billed charges are $400 or more above the total expected charges listed on the estimate. This $400 threshold triggers the patient’s right to dispute the bill.
To initiate the PDR process, an uninsured or self-pay patient must submit a request to the Department of Health and Human Services (HHS) or its designated entity. This action must be taken within 120 calendar days from the date they receive the initial bill that exceeds the GFE amount. An independent third-party, known as a Selected Dispute Resolution (SDR) entity, reviews the case, considering the GFE, the final bill, and supporting documentation from the provider. The SDR entity determines the appropriate amount the patient must pay, based on whether the provider can demonstrate that the higher charges reflect medically necessary, unforeseen circumstances.