How Good Faith Estimates Vary By Specialty

Despite over 90% of the US population having some form of health insurance, 20% of adults received a surprise medical bill in 2022. Healthcare is one of the only industries where patients do not know what they are paying until after the procedure or service is completed. With the rise in popularity of high deductible health plans, patients are being hit with bills they do not know are coming.  

Lawmakers have been busy over the past few years trying to help increase transparency in healthcare. Notably, the No Surprises Act was passed by Congress in December 2020 with two main purposes: 

1. Eliminate out-of-network costs for patients who are admitted into an in-network hospital 

2. Allow patients to understand costs prior to seeing a doctor or getting a procedure 

One of the main parts that allows patients to understand their healthcare costs before receiving care is the good faith estimate (GFE). Centers for Medicaid and Medicare Services (CMS), defines a good faith estimate as follows:  

Providers, co-providers, and facilities must supply the group health plan or patient (if self-insured) with a list of items and services they intend to offer to the patient, including facilities fees, hospital fees, and room and board, within 1-3 days of the care being scheduled. 

This sounds like a reasonable request, but in fact, GFEs can look vastly different across the different specialties of healthcare:

• For a primary care physician seeing a patient for a routine physical, the GFE could include the physician’s office physical fee, necessary lab work, and immunizations.  

• A more complex healthcare visit, such as a biopsy performed in an oncology center, would include specialized equipment, facility fees, anesthesia, and pathologist and oncologist services. 

• When a woman visits an OB-GYN to begin prenatal care, her doctor will perform a physical exam, ultrasound, routine blood and urine testing, and often times genetic screening, such as NIPT (non-invasive prenatal testing). 

Coordinating all these services into comprehensive good faith estimates requires close connection and communication with different co-providers and facilities. There are technology companies who are looking to help and careviso is one of them. Contact us to get a demo of seeQer today.