CMS Delays Enforcement of Co-Provider Requirement under the Good Faith Estimate – No Surprises Act Update
On December 2, 2022, the Centers for Medicare & Medicaid Services (CMS) announced it would delay the requirement to include cost estimates from co-providers and co-facilities in a good faith estimate (“GFE”) for self-pay or uninsured individuals. Previously, CMS said it would begin enforcing this provision of the law beginning January 1, 2023; however, it announced extending “enforcement discretion, pending future rulemaking.”
Under the No Surprises Act, a GFE must include expected charges for any item or service that is reasonably expected to be provided to uninsured and self-pay patients in conjunction with the scheduled or requested item or service, including those provided by co-providers or co-facilities. The co-providers and co-facilities must submit GFE information within one business day of a convening provider’s request. CMS indicated that enforcement of this requirement was slated to start on Jan. 1, 2023. However, providers have expressed concerns regarding compliance with the GFEs’ strict statutory timeframe and requested CMS further delay of enforcement of this provision until CMS establishes standard technology to automate the creation of GFEs and give providers and facilities sufficient time to implement such standards.
CMS believes that providers will need to widely adopt “standards-based application programming interface (API)” in order to “achieve industry-wide interoperability for the transmission of GFE data between convening providers and facilities and co-providers and co-facilities.” The Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) standard could support the interoperability providers need to deliver compliant GFEs to patients, CMS adds.
As a reminder, the states are primary enforcers of the GFE requirement. CMS encourages states to take a similar approach and “will not consider a state to be failing to substantially enforce these requirements if it takes such an approach while CMS is exercising enforcement discretion.”
 Centers for Medicare & Medicaid Services, FAQs About Consolidated Appropriations Act, 2021 Implementation – Good Faith Estimates (Gfes) For Uninsured (Or Self-Pay) Individuals – Part 3, Dec. 2, 2022.
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