What Law Requires Medical Providers To Give Patients An Itemized Statement Of Services Rendered?

New billing disclosure requirements take effect in 2022

Psychologists will demand to provide estimated costs of services before starting treatment.

Appointment created: December x, 2021 9 min read

Comment:

Commencement Jan ane, 2022, psychologists and other wellness intendance providers will be required by law to requite uninsured and self-pay patients a good organized religion approximate of costs for services that they offer, when scheduling care or when the patient requests an estimate.

This new requirement was finalized in regulations issued October seven, 2021. The regulations implement part of the "No Surprises Act," enacted in December 2020 as role of a wide package of COVID- and spending-related legislation. The deed aims to reduce the likelihood that patients may receive a "surprise" medical bill by requiring that providers inform patients of an expected charge for a service before the service is provided. The authorities will also presently effect regulations requiring psychologists to requite good faith estimates to commercial or government insurers, when the patient has insurance and plans to employ information technology.

Psychologists working in grouping practices or larger organizational settings and facilities will likely receive direction from their compliance department or lawyers on how to satisfy this new requirement.

Read on for answers to FAQs that apply to practicing psychologists who care for uninsured or self-pay patients.

What providers and what services are subject to this rule?

"Provider" is defined broadly to include any wellness care provider who is acting within the scope of the provider'south license or certification under applicable state police. Psychologists come across that definition.

The definition of "items and services" for which the good faith estimate must be provided is also broadly defined to encompass "all encounters, procedures, medical tests, … provided or assessed in connection with the provision of wellness care." Services related to mental wellness substance use disorders are specifically included.

What steps do I need to take and when?

Psychologists are ethically obligated to talk over fees with patients upfront. This new requirement builds on that by calculation more than construction and specific timeframes for activeness.

Under the new dominion, psychologists and other providers must accept the following steps for their uninsured or self-pay patients:

Ask if the patient has any kind of health insurance coverage (including government insurance programs similar Medicare, Medicaid, or Tricare), and if so, whether the patient intends to submit a claim to that insurance for the service.
Inform all uninsured and self-pay patients that a good religion guess of expected charges is
- available in a written certificate that is articulate, understandable, and prominently displayed;
- orally provided when the service is scheduled or when the patient asks about costs; and
- available in accessible formats, and in the language(southward) spoken by the patient.
Provide a skillful faith estimate of expected charges for a scheduled or requested service, including items or services that are reasonably expected to exist provided in conjunction with such scheduled or requested item or service." That judge must be provided within specified timeframes:
- If the service is scheduled at to the lowest degree three business days before the engagement appointment, no later than ane business 24-hour interval after the date of scheduling;
- If the service is scheduled at least 10 business days before the date date, no later than three business days afterwards the date of scheduling; or
- If the uninsured or self-pay patient requests a good faith guess (without scheduling the service), no later than iii business days later the date of the request. A new skillful faith gauge must be provided, within the specified timeframes if the patient reschedules the requested item or service.

If whatsoever information provided in the estimate changes, a new good faith estimate must be provided no subsequently than i business solar day earlier the scheduled care. Also, if there is a change in the expected provider less than one business day before the scheduled intendance, the replacement provider must accept the original good faith gauge as their expected charges.

What is the good faith guess based on?

The good faith estimate is a notification of expected charges for a scheduled or requested service (or item). The "expected charge" for an detail or service is either:

the cash pay charge per unit or rate established past a provider for an uninsured (or self-pay) patient, reflecting whatever discounts for such individuals; or
the amount the provider would expect to charge if the provider intended to pecker a health care program directly for such item or service.

Is the adept faith guess bounden?

The data provided in the good faith estimate is only an estimate, and the actual items, services, or charges may differ from what is included in the proficient faith estimate. However, uninsured or self-pay individuals may challenge a beak from a provider through a new patient-provider dispute resolution process if the billed charges substantially exceed the expected charges in the skilful faith approximate. Essentially exceeds means an amount that is at least $400 more than than the expected charges listed on the good organized religion guess for a specific provider.

What data should the good faith gauge contain?

The Centers for Medicare and Medicaid Services (CMS) have provided instructions and a sample expert religion estimate template (PDF, 163KB). A proficient faith estimate (PDF, 130KB) must contain the following information in clear and understandable language:

The patient's name and date of birth;
A description of the main item or service being furnished to the patient (and if applicable, the date the primary item or service is scheduled);
An itemized list of items or services that are "reasonably expected" to be furnished;
Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;
The name, National Provider Identifier, and Tax Identification Number (TIN) of each provider or facility represented in the adept faith estimate, and the country(due south) and function or facility location(southward) where the items or services are expected to be furnished. (APA recommends using a business organisation Can rather than your SSN);
A list of items or services that the provider or convening facility (the provider or facility that handles the scheduling of the service) anticipates will require separate scheduling and that are expected to occur before or following the expected period of intendance for the primary item or service; ¹
A disclaimer that in that location may be additional items or services the convening provider or convening facility recommends as part of the course of intendance that must be scheduled or requested separately and are non reflected in the good religion estimate;
A disclaimer that the information provided in the good religion gauge is only an estimate and that actual items, services, or charges may differ from the good religion estimate; and
A disclaimer that informs the patient of their right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the good organized religion estimate. This should include instructions for where the patient can find data about how to initiate the dispute resolution process, likewise equally a argument that the initiation of a patient-provider dispute resolution process volition not adversely affect the quality of wellness care services furnished to the patient; and
A disclaimer that the good faith gauge is non a contract and does not crave the uninsured (or self-pay) private to obtain the items or services from whatsoever of the providers or facilities identified in the good faith estimate.

The required disclaimers are included in the CMS template cited above.

¹ If in that location are such separately scheduled services, the gauge should likewise include a disclaimer that (a) separate good faith estimates will be issued upon scheduling or upon asking of the listed items or services, (b) for items or services included in this list, information such as diagnosis codes, service codes, expected charges and provider or facility identifiers practise not need to be included, as that information will be provided in divide expert faith estimates upon scheduling or upon request; and (c) instructions for how an uninsured (or self-pay) individual tin obtain good organized religion estimates for such items or services.

Do these requirements apply to existing/ongoing patients?

The dominion makes no distinction betwixt current and hereafter patients. These new disclosure requirements would presumably apply to continued services furnished to existing patients equally well as to new patients.

Special scenarios

Tin can I provide a single good organized religion estimate to a patient who I anticipate treating throughout the twelvemonth?

Yes. If you wait to provide a recurring service to the uninsured/self-pay patient, you are allowed to submit a unmarried good faith estimate to that patient for those services, so long as: (1) the good faith estimate includes, in a clear and understandable fashion, the "expected scope of the recurring primary items or services (such as timeframes, frequency, and total number of recurring items or services)"; and (2) the proficient faith estimate can simply include recurring services that are expected to be provided within the next 12 months. For boosted recurrences across 12 months, the provider must provide a new proficient organized religion approximate and communicate whatsoever changes betwixt the initial and the new estimates.

For example, if y'all have a psychotherapy patient that yous expect volition need continuing therapy throughout the year, the expert faith approximate might say the post-obit:

I wait that my care of you will require continued weekly therapy sessions continuing through the finish of the year, at $X per session for a total of 50 weeks, accounting for vacations and holidays for an estimated total of [$Ten x fifty].

Or if the future course of treatment is less certain, an estimate might look similar this:

Depending on the progress we make this year, I await that you will need 10–20 more sessions this year. At $X per session the estimated total cost would be [10X–20X].

I provide services in a setting offering multiple kinds of services to the aforementioned patient (i.e., a federally qualified health center, rural health clinic, hospital), and I practise not separately schedule appointments or bill for my services. Does this rule apply to me?

The regulation describes slightly different obligations for a "convening provider or convening facility," which is a provider or facility who receives the patient's request for a proficient faith estimate of costs and is responsible for scheduling the primary particular or service.

Depending on how appointment requests are received and scheduled in your setting, psychologists who work at these types of facilities might not be responsible for compiling or providing the expert religion estimate, but they are expected to contribute whatever information that may be relevant to the estimate.

If yous are in such a setting, yous should consult with your facility or dispensary'due south compliance officer or attorney about your personal obligations under this new regulation.

My patient is insured and intends to use their insurance to pay for my services. How do I send this data to the patient's insurance plan?

Federal agencies will soon issue rules specifying the class, timing, and way past which good religion estimates must be transmitted to insurers. APA will provide farther updates when these rules are issued. The data in this FAQ is just meant to apply to communication with patients who are self-pay or uninsured.

Disclaimer: Legal problems are complex and highly fact-specific and state-specific. They require legal expertise that cannot be provided in this article. Moreover, APA/APA Services attorneys practice not, and cannot, provide legal advice to our membership or land associations. The information in this commodity does non constitute and should not be relied upon as legal advice and should non be used as a substitute for obtaining personal legal advice and consultation prior to making decisions.

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