HHS clarifies FQHC medical bill estimate requirements

The Department of Health and Human Services (HHS) recently issued guidance about federally qualified health centers’ (FQHCs) obligation to issue a good faith estimate (GFE) to uninsured and self-pay patients.

The guidance clarifies that a provider or facility must list the undiscounted price for each item or service included in the GFE when there is not sufficient information (e.g., income or family size) to determine an individualized price when the item or service is scheduled. HHS encourages providers and facilities to also include information about sliding fee schedules and any other financial protections they offer.

The HHS guidance notes that if an established patient informs a provider or facility that their income or family size has changed from the information on file, the provider or facility may either rely on the information on file to generate the GFE or develop a new patient GFE that lists the undiscounted price of the items or services. For any established patient, HHS recommends providers and facilities include a disclaimer on the GFE indicating that the estimate is based on financial information on file and actual charges may differ based on changes in the individual’s financial circumstances.

The guidance also clarifies that physicians are required to issue GFEs to uninsured and self-pay patients even when they will furnish the services free of charge, but only an abbreviated GFE is required in those circumstances (the guidance includes an abbreviated GFE template).

The GFE requirement is part of the No Surprises Act, which took effect last year. The GFE is a notification that outlines an uninsured or self-pay individual's expected charges for a scheduled or requested item or service. (Self-pay patients are those who are enrolled in a health plan but will pay out of pocket and not submit a claim.) For individuals who schedule care at least three business days in advance, the GFE must be provided within one business day after the date of scheduling. If care is scheduled at least 10 business days in advance, the GFE must be provided within three business days of scheduling. If an individual requests a GFE or asks to discuss the cost of an item or service without scheduling it, the GFE must be provided with three business days of the request.

For more information, see these Centers for Medicare & Medicaid Services FAQs:

• Dec. 21, 2021, CMS FAQs
• April 5, 2022, CMS FAQs
• Dec. 27, 2022, CMS FQHC FAQs

— Brennan Cantrell, AAFP Commercial Health Insurancer Strategist

Posted on Jan. 27, 2023