The CAP asked the Biden administration to consider the burden and potential misuse of data by insurers in comments regarding upcoming good faith estimates (GFE) regulations. The new regulations, which have not yet been released, would implement requirements around an “advanced explanation of benefits” and additional GFE requirements of the No Surprises Act.

Specifically, the new regulations will address those circumstances where an individual has health insurance and is seeking to have a claim for an item or service submitted to their insurer. Providers and facilities must already provide a GFE to uninsured or self-pay patients, but for covered individuals, will eventually have to provide a GFE of the expected charges to the insurer. The insurer will then use this information to send the patient an advanced explanation of benefits (AEOB).

In the November 14 letter, the CAP urged the CMS to streamline the GFE process while reducing burdens on pathologists. Additionally, the CAP asked the CMS to maximize the information that health insurers can provide to avoid duplication of efforts. The CAP has repeatedly emphasized the significance and complications in determining the cost of pathology services in advance of services conducted by the pathologist.

The CAP also asked the CMS to add protections and limits on data disclosed to insurance companies. This should include “measures to explicitly prevent insurers from using AEOB and GFE data for anything other than the provision of advanced estimates.”

Reminder: Good Faith Estimates Resources Available for Pathologists

Beginning in 2022, the 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 webinar, toolkit, and a podcast.