Medlearn Media NPOS Non-patient outcome spending

Most providers understand the “No Surprises” requirements for insured patients. Effective as of Jan. 1, 2022, uninsured (or self-pay) consumers are also protected from unexpected high medical bills.

If a consumer doesn’t have health insurance or doesn’t plan to use insurance to pay for health care items or services, they must be given a “good faith estimate” of what they may be charged, before they get the item or service.

Once an uninsured patient  schedules a visit, or with a health care provider or health care facility, that provider or facility must give them a good faith estimate of the amount it expects to charge for that item or service. A provider or facility must also give this good faith estimate when a consumer requests it (regardless of if they schedule the item or service).

There is a patient-provider dispute resolution process now available for uninsured patients who get a bill from a provider that’s at least $400 more than the expected charges on the good faith estimate.

Under the patient-provider dispute resolution process, an uninsured (or patient, or their authorized representative), may initiate the dispute process. This process brings in an independent third-party called a dispute resolution entity to determine the appropriate amount the consumer must pay.

If a consumer chooses to dispute a charge for an item or service, the provider will be asked to provide the following:

  • The good faith estimate they provided their patient.
  • The bill they sent to their patient.
  • Any supporting documents that help to explain why the bill is higher than the estimate.

Providers will be emailed a link to the federal dispute resolution portal where they can upload the requested documents. The dispute resolution entity will contact the provider if any additional information is needed. Once a determination is made, the dispute resolution entity will notify the provider and the patient.

During the patient-provider dispute resolution process, the provider and patient can continue to negotiate the bill. During this process, providers:

  • May not move the bill into collections or threaten to do so.
  • Must pause collections if the bill is already in collections.
  • Can’t collect late fees on unpaid amounts.
  • Can’t threaten to take any retaliatory action against the patient for initiating the patient‑provider dispute resolution process.

If the provider and patient agree on a payment amount before the dispute resolution entity makes a determination, the provider must notify the dispute resolution entity as soon as possible, but no later than three days after the settlement. Providers should complete this notice of payment settlement (PDF) (en Español) (PDF), and send it and any supporting documents by encrypted email to FederalPPDRQuestions@cms.hhs.gov.

Get more information about the good faith estimate and the patient-provider dispute resolution process.

Programming note: Listen to Tim Powell’s live reports every Tuesday on Talk Ten Tuesday with Dr. Erica Remer and Chuck Buck, 10 Eastern.

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Timothy Powell, CPA

Timothy Powell is a nationally recognized expert on regulatory matters, including the False Claims Act, Zone Program Integrity Contractor (ZPIC) audits, and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) compliance. He is a member of the RACmonitor editorial board and a national correspondent for Monitor Mondays.

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