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Guidance on Patient-Provider Dispute Resolution Process

Last month, the Centers for Medicare & Medicaid Services (CMS) released guidance on good faith estimates and the patient-provider dispute resolution (PPDR) process for providers and facilities.

The PPDR process was established under part II of the No Surprises Act interim final rule. An uninsured or self-pay patient may initiate the PPDR process if they receive a bill from a provider that is $400 over the expected charges listed on the good faith estimate (GFE).

Good Faith Estimates

The GFE outlines an uninsured patient’s expected charges for a scheduled or requested service. Convening providers must consider any discussion or inquiry regarding potential costs of service as a request for a GFE.

Providers still have up to three business days to provide a GFE to patients. They also must reach out to coproviders who are reasonably expected to provide services during the same episode of care to submit GFE information within one business day. CMS will exercise enforcement discretion through Dec. 31, 2022, in situations in which a GFE does not include expected charges from a coprovider to allow providers to establish efficient communications channels to transmit this information. Further, convening providers and coproviders will have one business day to provide a new GFE if any changes to the scope of the previous GFE are anticipated or made.

Providers are allowed to provide a single GFE for recurring services if the estimate includes expected scope of service, such as timeframe, frequency, and total number of services, and does not exceed 12 months.

Estimates are required to be provided in written or electronic form. If a patient requests an estimate in another form, such as by phone or orally in person, the provider may do so, but must also furnish a good faith estimate in written form.

Finally, a provider will not fail to comply with federal GFE requirements if the provider makes an error or omission on the estimate if they are acting in good faith and correct the information as soon as practicable.

CMS has provided example templates for many of the forms required for GFE, notices, and disclaimers.

Patient-Provider Dispute Resolution Process

The PPDR process is available to any uninsured or self-pay patient who receives a bill from a provider that is $400 higher than the GFE. Under the process, the patient may seek a payment determination from a selected dispute resolution (SDR) entity.

As mentioned above, CMS will use enforcement discretion for GFEs that do not include expected charges for services from coproviders through Dec. 31, 2022. During this period, services expected to be provided by coproviders that appear on the GFE but do not include a cost estimate will not be eligible for the PPDR process. If expected charges appear on the GFE, they will be eligible for the PPDR process.

After the patient receives a bill, they will have 120 calendar days to initiate the PPDR process. Patients are strongly encouraged to use the federal IDR portal to submit an initiation notice. The SDR entity will review the notice, ensure services are eligible for the PPDR process, and notify the provider the request is under review. The provider then will have 10 business days to submit:

  • a copy of the GFE provided to the patient;
  • a copy of the billed charges provided to the patient for the services under dispute; and
  • if available, documentation providing evidence to demonstrate the difference between the expected charges and billed charges reflects the cost of medically necessary services and is based on unforeseen circumstances that could not have been reasonably anticipated by the provider when the GFE was provided.

The SDR entity will have 30 business days to make a payment determination and will compare each service individually to the GFE amount. They will determine how much the patient must pay based on documentation submitted by the provider.

If the SDR entity finds that the documentation does not support the additional billed charges, the patient will pay the amount on the GFE. If the SDR entity decides the documentation supports the additional billed charges because the service not listed on the GFE was medically necessary and unforeseen, the patient will pay the lesser of:

  • the billed charge; or
  • the median payment amount paid by a plan or issuer for the same or similar service by a same or similar provider in the same geographic area, unless this amount is lower than the expected charge listed on the GFE. If that is the case, the patient will pay the amount listed on the GFE.

If the SDR entity determines the payment amount to be less than the billed charges, the patient will recover the $25 administrative fee from the payment amount.

Patients and providers can agree to resolve the dispute by settling on a payment amount during the PPDR process and split the administrative fee. The provider must notify the SDR entity of this settlement within three business days.

Finally, payment of a billed charge or portion of a billed charge by the patient prior to a determination does not demonstrate agreement by the individual to settle at that amount.

CMS also released guidance on the PPDR process for patients, as well as guidance for SDR entities.

Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Julie Kozminski is a policy manager at America's Essential Hospitals.

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