Earlier this summer, the American Medical Group Association (AMGA) sent a letter to the United States Centers for Medicare and Medicaid Services (CMS), raising concerns about the good faith estimate process and the way it has resulted in greater administrative burden for medical groups.
The letter was an expansion of comments on the Requirements Related to Surprise Billing; Part II (86 FR 55980) of the Interim Final Rule (IFR) issued by the Department of Health and Human Services (HHS), Treasury, and Labor, and the Office of Personnel Management on September 30, 2021. AMGA notes that while it “supports the spirit of the transparency provisions in the No Surprises Act,” and its member groups “appreciate the value of developing a culture of transparency to empower patients to make informed decisions about their healthcare,” there were concerns about the current implementation of good faith estimate requirements.
The letter states that the rigidity of the good faith estimate timeliness notification standards do not “account for provider workflows, nor do they afford sufficient time to gather required information.”
In the letter, AMGA outlined problems with the requirements, which have resulted in significant challenges for providers, including the ability to effectively schedule, coordinate, and deliver care. AMGA members have raised concerns in three main areas: confusing and conflicting guidance, staffing constraints, and the cost and lack of infrastructure to complete good faith estimates.
Unclear Guidance
AMGA notes that while HHS has made some information and resources available on good faith estimates, there are inconsistencies between guidance for providers and for patients. The letter cites several examples, including patient guidance that states: “[i]f you schedule the item or service at least 10 business days before the date you will receive it, or request cost information about an item or service, the provider or facility must give you a good faith estimate no later than 3 business days after scheduling or requesting[;]” however, this does not account for services requested by a patient less than 3 business days in advance. Similarly, Part II of the GFE FAQs indicate that a GFE is not required for items or services scheduled fewer than 3 business days before the expected date they are expected to be furnished, but this does not address situations in which a GFE is expressly requested by a patient.
Staffing
AMGA also points to the “healthcare workforce crisis unlike any other,” and notes that AMGA members are “experiencing significant staffing needs and recruitment challenges.” AMGA further notes that the skillset to perform good faith estimates includes various aspects of the medical field, including knowledge about clinical, coding, and financial issues, and is not something most employees tend to have.
Cost and Infrastructure
Finally, when it comes to cost and infrastructure, AMGA notes that its members have had to invest in infrastructure changes to provide good faith estimates to uninsured and self-pay patients. Additionally, there are expenses of having to mail hard copies of the estimates and storing the estimates in electronic health records (EHRs).
AMGA Requests
AMGA members report completing more than 45,000 good faith estimates per month and only expect that number to increase. Therefore, AMGA is asking CMS to work with key stakeholders to develop a new process in which good faith estimates are not only beneficial to patients, but also do not result in administrative burdens on providers.
More specifically, AMGA requests a meeting with CMS, as well as the additional requests of the Department of Health and Human Services (HHS):
- That HHS exercise enforcement discretion in additional areas
- That HHS provide updated guidance clearly outlining when good faith estimates are required and the extent of reasonable and expected services for which cost estimates are required
- That HHS also work with stakeholders to clarify guidelines, address staffing shortages, and help provide a cost-effective infrastructure for good faith estimates.
“The current GFE requirements impose additional stress to an already strained healthcare workforce,” said AMGA President and CEO Jerry Penso, M.D., M.B.A. “CMS should reform the process so that the estimates provide the information patients need, without creating new administrative obstacles for providers to overcome.”