A Good Faith Estimate (GFE) is a projection of the costs a patient can expect to pay for scheduled medical services. This document increases transparency in healthcare pricing, offering patients a clear outlook on their financial responsibility before receiving care. It serves as a pre-service cost projection for patients who are not using health insurance (self-pay), helping them budget and make informed decisions about their treatment plan.
Defining the Good Faith Estimate
The Good Faith Estimate is a formal, legally required document intended to protect consumers from unexpected medical bills. It is mandated for uninsured individuals or those who are “self-pay,” meaning they choose not to use their existing health insurance for a particular service. The GFE estimates the total expected costs for any non-emergency items or services, including related charges such as medical tests, prescription drugs, and facility fees.
This consumer protection measure was established under the No Surprises Act (NSA), effective January 1, 2022. The law requires all healthcare providers and facilities to furnish this estimate to eligible patients upon request or when a service is scheduled. The GFE is not a final bill, but it represents the provider’s honest effort to capture all foreseeable charges based on the information available at the time of scheduling.
The estimate must be given for scheduled services, preventing surprise billing in non-emergency situations. Providers are responsible for providing the GFE, which legally binds them to a reasonable expectation of charges for the services listed. Its purpose is to shift the burden of unexpected costs away from the patient by requiring clear disclosure beforehand.
When and How You Receive the Estimate
The timeline for receiving a Good Faith Estimate depends on how far in advance the medical service is scheduled. If a service is scheduled at least 10 business days away, the provider must provide the GFE within three business days of scheduling. This allows the patient ample time to review the expected costs.
If a service is scheduled closer to the date, such as at least three business days in advance, the deadline is accelerated. The GFE must be furnished no later than one business day after the service is scheduled. If an uninsured or self-pay patient asks for an estimate without scheduling a service, the provider must still provide the document within three business days of the request.
The responsibility falls on the “convening provider” or “convening facility,” which is primarily responsible for the service. This entity must collect expected cost information from all other co-treating providers or co-facilities involved in the care (such as anesthesiologists or labs) and include those charges in the single GFE. The estimate must be delivered to the patient in writing, electronically or on paper, depending on the patient’s preference.
Components of the Estimate
A compliant Good Faith Estimate must contain a detailed, itemized list of all expected charges associated with the scheduled care. This list must include all items and services expected to be furnished as part of the primary service, such as facility fees, supplies, drugs, and medical equipment. The document must also clearly identify the patient by name and date of birth.
For each item and service listed, the GFE must include both the expected charges and the corresponding service codes. Service codes, such as Current Procedural Terminology (CPT) codes, describe the specific procedure or service provided in medical billing. While treatment codes are always required, diagnosis codes (often from the International Classification of Diseases, or ICD, system) are only required if necessary for calculating the estimate.
The estimate must list the names and tax identification numbers of the convening provider and all co-providers and co-facilities involved in the care. The inclusion of specific codes allows the patient to research the listed services and compare costs. By detailing all co-treating providers, the GFE ensures the patient sees a comprehensive cost projection for the entire episode of care.
What to Do When the Bill Exceeds the Estimate
A patient has recourse if the final medical bill is substantially higher than the amount listed on the Good Faith Estimate. The law defines a “substantially in excess” bill as one where the total billed amount from any single provider or facility is $400 or more above the total expected charges listed for that provider on the GFE. In this situation, the patient may initiate the Patient-Provider Dispute Resolution (PPDR) process.
The PPDR process allows an uninsured or self-pay patient to challenge the discrepancy using an independent third party, known as a Selected Dispute Resolution (SDR) entity, to review the charges. To start the dispute, the patient must file a request within 120 calendar days of receiving the final bill. The patient must submit both the original GFE and the final bill to the SDR entity for review.
The independent third party determines the appropriate amount the patient must pay, which can be the estimated amount, the billed amount, or an amount in between. This mechanism serves as a safety net, ensuring that providers adhere to the cost transparency mandate of the GFE. Patients should save a copy of their GFE to use as evidence if they need to dispute the final charges.