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- CAP Reviewing Agency Request for Information on Advanced Explanation of Benefits
On September 16, the Department of Labor, Department of Health and Human Services (HHS), and the Treasury released a request for information (RFI) that will inform future rulemaking for the advanced explanation of benefits and additional good faith estimate (GFE) requirements of the No Surprises Act. Unlike the current GFE requirements for self-pay/uninsured patients, the upcoming rulemaking will implement requirements that where an individual has health insurance and is seeking to have a claim for such item/service submitted their insurer, providers/facilities must provide to the insurer a GFE of the expected charges. This information will then be used by the insurer to send to the patient an advanced explanation of benefits.
The CAP has continually stressed the significant – and particular – difficulty in determining the cost of pathology services in advance of services conducted by the pathologist and will be submitting comments to the departments by the November 15 deadline.
Reminder: Good Faith Estimates Resources Available for Pathologists
Beginning in 2022, the Centers for Medicare & Medicaid Services (CMS) implemented good faith estimate requirements for physician and other provider practices.
Specifically for pathologists, these requirements mandate that a good faith estimate of expected charges be provided to uninsured or self-pay patients at least three business days before a scheduled service or upon request. This must include expected charges for the items or services provided in conjunction with the primary item or service. A good faith estimate is not required to include charges for unanticipated items or services that are not reasonably expected and that could occur due to unforeseen events.
The CAP has resources to help members understand the good faith estimates and price transparency for diagnostic medicine, including a toolkit and a podcast.