WEDI Voices Concerns About Good Faith Estimates Implementation

The Workgroup for Electronic Data Interchange (WEDI) expressed concerns to CMS regarding the good faith estimates policy under the No surprises Act and the problems it causes for providers and patients alike.

In response to a request for information about the No Surprises Act from CMS, WEDI submitted comments to Kathleen Cantwell, director of the CMS Office of Strategic Operations and Regulatory Affairs.

While WEDI agreed with the No Surprises Act goal of protecting patients from surprise medical bills, the organization voiced its worries about the good faith estimates regulation and the patient-provider dispute resolution process.

The good faith estimates policy requires providers to present uninsured and self-pay patients with an estimate for their planned healthcare services.

WEDI affirmed that the policy’s intent is valid, but it presents obstacles and creates burden for providers.

First, WEDI raised concern about when providers should provide a good faith estimate. The organization suggested that instead of automatically providing estimates for all uninsured and self-pay patients, providers should only give estimates to patients who request them.

“We are concerned that if the requirement on the industry is to initiate the GFE process for every service scheduled with a provider or facility, it will not only add considerable burden for providers and facilities but could be counterproductive for the patient,” the letter stated.

For example, patients who receive an estimate that they did not request may be confused about whether it is their final bill and why they receive it before their appointment.

Additionally, WEDI said that developing a good faith estimate prior to seeing the patient would make it difficult for providers to assess the services needed and produce an accurate estimate. The range of services could also change once the provider sees the patient, potentially becoming more costly or complicated. This could make the final bill differ significantly from the estimate and pass the $400 arbitration threshold.

WEDI also noted that patients could receive inaccurate cost estimates due to the estimate failing to account for discounts for financially disadvantaged patients. Patients usually apply for discounts after the provider evaluates them and determines the exact services they will need.

The trade group suggested that CMS extend the timeframe for good faith estimates to incorporate the discounts or not require facilities to include the discounts in the estimates.

According to WEDI, the current timeframe for good faith estimates is one to three business days. While the organization understood that it is vital that patients receive estimates promptly, the letter noted that the timeline is challenging for providers to meet. Providers may struggle with the timeline particularly if a convening provider or facility is involved.

The good faith estimate requirements will create substantial burden for all providers, but small rural practices will especially feel the pressure, WEDI added.

Finally, WEDI expressed concern about the patient-provider dispute resolution process in the good faith estimates policy. The regulation states that if a patient’s final bill is more than $400 higher than the initial estimate, the patient can start a dispute resolution process.

The letter stated that CMS should change this threshold to a percentage instead and apply the threshold to each service and not a bundle of services.

In addition, WEDI noted that significant differences between the final bill and the initial estimate may result from clinical outcomes, such as additional time in the hospital to recover or anesthesia required for the service.

“It would be unfair to penalize a provider or facility for variations beyond their control, WEDI wrote. “Adopting a percentage threshold could better account for variability and potentially avoid inflated GFEs, produced to mitigate risk, that would be less useful to the patient.”

The American Hospital Association (AHA) recently penned a letter to CMS, expressing similar concerns about the good faith estimates policy.

In January, the Medical Group Management Association (MGMA) also called on CMS and HHS to delay enforcement of the good faith estimates regulation, stating that medical practices faced administrative burden and needed more time to understand the rules and execute a strategy.