Remove Burdens from Surprise Billing Rule, AAFP Tells CMS

The AAFP was responding to a second round of the agency’s implementation guidance for 2020’s No Surprises Act, popular legislation that went into effect Jan. 1 and solidified a number of patient protections for which the AAFP had long advocated. The Requirements Related to Surprise Billing; Part II rule requires physician practices to ask patients their health insurance status and whether they will make an insurance claim for the care being sought; the physician must provide a good-faith estimate of expected charges for items and services to any uninsured or out-of-pocket patient.

“Family physicians report that it is adding to their administrative burden,” the Academy said of this requirement, which also began Jan. 1, and which the AAFP said should not be enforced as written. “The AAFP urges CMS to delay enforcement of the good faith estimate requirement and make several modifications in the final rule to avert care delays and reduce the unnecessary burden this requirement imposed on primary care practices, including direct primary care practices.”

The letter, sent to CMS Administrator Chiquita Brooks-LaSure and signed by Board Chair Ada Stewart, M.D., of Columbia, S.C., echoed the Academy’s call for sharper focus on administrative simplification last year in its comments on the first portion of CMS’ rulemaking. It answered a follow-up request for information from CMS, published in the Jan. 7 Federal Register, attached to the second part of the rule.

The Academy expressed agreement with CMS that such estimates would improve patients’ understanding of their care costs and could help them avoid unexpected medical bills. However, the letter said, assembling GFE for new patients or patients with new medical problems — essentially by guessing diagnosis and procedure codes — is already challenging some practices.

“In a family medicine practice, where physicians provide comprehensive primary care services to patients across the lifespan, the relevant conditions, history and symptoms can be quite extensive,” the letter said. “Other services can include a wide array of screenings, vaccinations, routine lab testing and other preventive care services, in addition to chronic care management services and minor procedures. It is unreasonable and inappropriate to require administrative staff to try to obtain this level of information about a patient’s condition and history over the phone when they are scheduling an appointment.

“Many patients are also uncomfortable with sharing their private health information with administrative and clinical staff with whom they do not have an established, trusting relationship. Accordingly, primary care practices struggle to provide an accurate good faith estimate to new patients or those that are experiencing a new condition.”

Noting that the rule now requires practices to list expected diagnosis and procedure codes on the GFE, even in the absence of adequate information to make those determinations, the Academy called for flexibility to protect the patient-physician relationship and warned that the rule as written could lead to delays of care while practices gather patient details. A further requirement that practices specify which clinician will see a patient “could undermine team-based care and flexible scheduling arrangements, which improve care for patients and can lessen physician burnout,” the letter added.

“Some practices report they have had to hire or reassign staff to comply with the GFE requirements, which could worsen staffing shortages and result in care delays as practices continue to respond to the COVID-19 pandemic.”

With these concerns in mind, the Academy called on CMS to better align its rulemaking with the legislation’s intent by

• exempting primary care practices from the GFE requirement when patients make an appointment that is less than three full business days from the time of scheduling;
• removing the requirement that a specific clinician be identified on the GFE;
• offering an exception when a patient chooses to forgo receiving a GFE; and
• allowing primary care practices to provide an abbreviated GFE, excluding diagnostic or procedure codes, for new or complex patients.

The Academy also repeated its recommendation that CMS exempt DPC practices from the GFE requirement, arguing that patients who have contracted for DPC do not need a GFE to notify them of charges to which they’ve already agreed.

The letter urged subregulatory guidance exempting DPC practices from the GFE requirement when

• all the items and services that are reasonably expected to be provided are already included in the flat fee paid by the patient; or
• when additional, reasonably expected services not included in the flat fee are instead submitted by the patient to an insurer.

The AAFP added that future rulemaking should exempt DPC practices from the GFE requirement altogether “unless there is a reasonable expectation that the primary service, and/or related items and services, are not included under the flat fee and the patient opts to pay entirely out of pocket for those additional services.”