Thank you for joining us for this ASG sponsored webinar on new surprise billing regulations. My name is Eden Essex and I will be the announcer for this session. You will be able to submit questions and comments throughout the event via the Q&A box. Questions received in advance of today's session will be addressed first. The Q&A session will be held at the conclusion of the CMS presentation. The slide presentation for today's webinar is available to you in the chat. A recording of this session will populate your GI LEAP account when it is available next week so you can review the content anew or watch it with others. Now it is my pleasure to introduce the chair of the ASG Health and Public Policy Committee, Dr. Bruce Hennessey. Dr. Hennessey is a gastroenterologist and managing partner at Ohio Gastroenterology Group, a 36-physician, single-specialty gastroenterology group with five endoscopic surgery centers. I will now hand the presentation over to Dr. Hennessey. Thank you, Eden. Good afternoon. On behalf of the American Society for Gastrointestinal Endoscopy and as chair of the ASG's Health and Public Policy Committee, thank you for joining this ASG sponsored webinar on new surprise billing regulations. The new regulations, many of which became effective at the beginning of this year, implement the No Surprises Act that was passed by Congress at the end of 2020. The No Surprises Act is designed to protect patients from surprise or balanced billing when they unknowingly receive care from out-of-network providers at an in-network facility. Although the probability is low of a patient receiving a surprise bill for healthcare delivered in a physician-owned ambulatory endoscopy center because of the prior authorization process and anesthesia and pathology services often incorporated into the medical practices, there are still several requirements ambulatory endoscopy centers must meet now under the No Surprises Act regulations, including balanced billing protection disclosures, notice and consent for out-of-network care, and good faith estimates for non-emergency care provided to self-pay or uninsured patients. I know there are a lot of questions about the new requirements, what AECs and ASCs need to do to be in compliance. I am grateful representatives from the Centers for Medicare and Medicaid Services, including the team within the Center for Consumer Information and Insurance Oversight, are joining us to talk about these requirements and to answer your questions. Let's now turn the presentation over to Erin Sutton, Deputy Group Director with the Center for Consumer Information and Insurance Oversight. Thank you so much, Dr. Hennessey, and everyone in the membership today here for having CMS join the meeting. We have been, I know it's been some time since we've had a listening session with many of you that we started back in March, and we're really glad to be here again today now that we have launched a host of operational provisions for No Surprises Act, and I think what we also want to do here is really get to know your membership and the specific questions that you have, and I know that we have some that were submitted, so we're excited to get into that dialogue and really understand a little bit more of your business practice needs as well as it relates to No Surprises Act. So I just wanted to quickly go over a couple things that happened on January 1st before I turn it over to my colleague, Sam, who will go through a presentation about provider requirements and some of the balance billing provisions, and I just also want to introduce across the board my colleagues from CMS today. We have the best of the best on this call in terms of subject matter expertise for No Surprises, so we have a well-rounded team here that hopefully will be answering these questions live, and if not, we will publish them later as an FAQ. We're constantly updating our website, the nosurprises.gov website, because we know that we're getting a lot of frequently asked questions both through our call center and also from many of you in provider groups around the country, so we are trying to rapidly turn those around and answer them. So I just wanted to point out a couple of four key points here that happened on January 1st, and there was a lot building up to this, but as many of you know, the legislation passed December of last year, so we've been heads down, busy at work, trying to get things up and running for the year that we had for implementation. And so the first thing that happened is consumer protection. So those are now effective, and that includes a ban on balance billing, the requirement to have a good faith estimate, notice and consent waivers when applicable. So those are the main key consumer protections that were put out in regulation earlier in the summer and are now effective as of January 1st. The second thing that is now effective is the investigation of complaints, and so that would include the No Surprises Help Desk, which is sort of our one-stop shop for no surprises when both consumers and providers call in with questions and or want to initiate a complaint. And then we also have, as I mentioned, our website, a number of online resources, and key to this is we also have a web form that you can initiate for complaints or inquiries as well, and those are all integrated with our No Surprises Help Desk. We also launched the Payment Dispute Resolution process, and that is the process for the uninsured or self-pay consumers that is between the consumer and the providers. And so that is up and running, and there is a web portal on our nosurprises.gov website that you can click through if you are initiating a Payment Dispute Resolution process. Then we also had a number of activities on the go live date of January 1, which are Stakeholder and Consumer Outreach and Education and also Provider Technical Assistance and Education. That sort of started, obviously, before we launched on January 1, and we are excited to be here with you as a technical assistance resource for your practices as we continue to host a number of sessions, both through the CMS Open Door Forums, and also we have a session called First Fridays for Clinicians that are periodically hosted, and we will also have a series of trainings that will continue throughout the year at a regular cadence on different topics to help you better understand the requirements of the law. And so with that, I will turn the presentation over to my colleague, Sam, to get more into detail about the provider requirements under the No Surprises Act, and then I understand later we will have a question and answer session, and that's when it gets really fun because we can get into the specifics. But for now, I'll turn it over to Sam. Thank you very much for having us. So, thank you. Thank you, Aaron, and thank you for inviting us to join today. My name is Sam Shaftson. I am with the U.S. Public Health Service and assigned to CMS and SOCIO, and I'm working on the Provider Enforcement Team. And today, I'll be providing a high-level overview of the provider requirements associated with the No Surprises Act. I will start by covering the background and purpose of the provider piece. I will outline the requirements for providers' facilities and providers of air ambulance services that took effect starting January 1st, 2022. I will go into more detail about each of the requirements, and then I'll talk a little bit about enforcement and follow on by highlighting some resources and definitions, and then, as Aaron said, we'll open it up for Q&A. So with that, I'll just jump right in. As part of the Consolidated Appropriations Act, the No Surprises Act amended Title 27 of the Public Health Service Act to add a new Part E. The provisions in Part E created requirements that apply to providers' facilities and providers of air ambulance services, such as cost-sharing rules, prohibitions on balance billing for certain items and services, notice and consent requirements, and requirements related to disclosures about balance billing protections. Generally, providers' facilities and providers of air ambulance services must comply with these new requirements as of the 1st of this year. These requirements apply to items and services provided to individuals enrolled in group health plans or group or individual health insurance coverage and federal employee health benefit plans. The good faith estimate requirement and the requirement to the patient-provider dispute resolution process also apply to the uninsured, and these requirements do not apply to beneficiaries or enrollees in federal programs such as Medicare, Medicaid, Indian Health Service, Veterans Affairs, health care, or TRICARE, and these programs, they already have existing protections in place to curb high medical bills. So at a high level, this slide and the next slide cover kind of the list of seven or so provider and facility requirements that took effect January 1st, so no balance billing for out-of-network emergency services, no balance billing for non-emergency services by non-participating providers at certain participating health care facilities, less notice and consent was given in some circumstances. Providers will be required to disclose patient protections against balance billing. Continuing on the next slide, balance billing for air ambulance services by non-participating air ambulance providers is prohibited. A good faith estimate must be provided in advance of scheduled services or upon request for uninsured or self-pay individuals. Providers must ensure continuity of care when a provider's network status changes, and there is a final requirement that deals with improving provider directories and reimbursing enrollees for errors. So I'll now go into greater detail on each of the requirements. Non-participating providers and non-participating emergency facilities cannot bill or hold liable members of group health plans or those enrolled in individual health insurance coverage, received emergency services at a hospital or an independent freestanding emergency department for a payment amount greater than the in-network cost sharing requirement for such services. And furthermore, cost sharing is calculated as if the total amount that would have been charged by a participating provider or participating facility were equal to the recognized amount. Certain post-stabilization services are considered emergency services and are therefore subject to this prohibition unless notice and consent requirements are met. Now regarding the requirement of no balance billing for non-emergency services by non-participating providers at certain participating health care facilities, unless notice and consent was given in some circumstances, non-participating providers and facilities may balance bill for post-stabilization services only if all of the following conditions have been met. So the attending emergency physician or treating provider determines that the beneficiary enrollee or participant can travel using non-medical or non-emergency medical transportation to an available participating provider or facility located with a reasonable travel distance, taking into account the individual's medical condition, and is in a condition to receive notice and provide informed consent. Continuing on to the next slide, the non-participating provider or participating facility provides the beneficiary enrollee or participant with written notice and obtains consent that includes certain content and within a specific time frame and format outlined in regulation guidance. I'll be sharing a resource slide later on in the deck that provides more information on this. The provider, and finally the provider or facility satisfies any additional state law requirements, something to take into account. So moving on to the next slide and still on notice and consent, a provider or facility cannot bill or balance bill for items or services furnished as a result of unforeseen urgent medical needs that arise at the time an item or service is furnished regardless of whether the non-participating provider or facility previously satisfied the notice and consent criteria. And it's important to note that this applies to both emergency and non-emergency services. So moving on to the next slide on the requirement of a no-balance billing for non-emergency services by non-participating providers and certain participating healthcare facilities, non-participating providers, excuse me, of non-emergency services at a participating healthcare facility cannot bill or hold liable members of health plans or group or individual health insurance coverage received covered non-emergency services with respect to a visit at a participating healthcare facility by a non-participating provider for a payment amount greater than the in-network cost sharing requirement for such services unless notice and consent requirements are met. Cost sharing is calculated as if the total amount that would have been charged by a participating provider or participating facility were equal to recognized amount. In this instance, healthcare facilities include hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgical centers. So moving to the next slide, it is important to note that notice and consent requirements do not apply to the following ancillary services for which the prohibition against balance billing remains applicable. So items and that includes items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, those that are provided by assistant surgeons, hospitalists, and intensivists, diagnostic services including radiology and laboratory services, and finally items and services provided by a non-participating provider if there is no participating provider who can provide such item or service at such facility. Okay, so now I'll briefly discuss the disclosure requirements. A provider or facility must disclose information regarding federal and state balance billing protections and how to report violations. Providers or facilities must post this information prominently at the location of the facility posted on a public-facing website if applicable and provide it to the participant, beneficiary, or enrollee. Okay, and the next requirement deals specifically with air ambulance services which may or may not be of interest to all members of the ASG community. I'm going to walk through those. Providers of air ambulance services cannot bill or hold liable beneficiaries, enrollees, or participants in group health plans or group or individual health insurance coverage who received covered air ambulance services from a non-participating air ambulance provider for a payment amount greater than the in-network cost sharing requirement for such services. The cost sharing requirement must be calculated as if the total amount that would have been charged for the services by a participating provider of air ambulance services were equal to lesser of the qualifying amount, you know, or a planned median contracted in-network rate or the billed amount for services. Okay, so the next two slides detail the good faith estimate requirement. A good faith estimate must be provided in advance of scheduled services or upon request, and this applies to uninsured or self-pay individuals. A healthcare provider or facility must inquire if an individual who schedules an item or service is enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, a federal healthcare program, or a federal employee health benefit plan. If so, they must inquire if the individual enrolled in one of these plans is seeking to have their claims for such item or service submitted to the plan. The provider or facility must then provide notification of the good faith estimate of the expected charges, expected service, and diagnostic codes of scheduled services. And some more on the good faith estimate, the GFE must include expected charges for the items or services that are reasonably expected to be provided in conjunction with the primary item or service, including items or services that may be provided by other providers and facilities. And from January 1st of this year through December 31st, 2022, HHS will exercise its enforcement discretion in situations where a good faith estimate provided to an uninsured or self-pay individual does not include expected charges from other providers and facilities that are involved in the individual's care. Something of note is that CMS has posted a series of FAQs on the GFE topic. I know a number of GFE questions were submitted in advance of this session today, so we have a few subject matter experts on the line to field some of those, but just wanted to make note of those FAQs. So on the next slide, providers must ensure continuity of care when a provider's network status changes. So a healthcare provider or facility that ends a contractual relationship with a plan or issuer and has a continuing care patient must generally accept payment from the planner, issuer, and cost-sharing payments for a continuing care patient at the previously agreed-to payment amount for up to 90 days after the date on which the patient was notified of the change in the provider's network status. In particular, this applies to cases where the contractual relationship between a plan or issuer and a provider or facility ends, resulting in a change in the provider or facility's network status within the plan. Providers and facilities should continue to adhere to all policies, procedures, and quality standards imposed by the plan or issuer for such items or services as if the contract were still in place. And there is a final requirement that deals with improving provider directories and reimbursing enrollees for errors. Any healthcare provider or healthcare facility that has or has had a contractual relationship with a plan or issuer to provide items or services under such plan or insurance coverage must submit provider directory information to a plan or issuer at a minimum at the beginning of the network agreement with a plan or issuer at the time of termination of a network agreement with a plan or issuer when there are material changes to the content of the provider directory information of the provider or facility upon request by the plan or issuer and at any other time determined appropriate by the provider facility or HHS. And just a little more on improving provider directories and reimbursing enrollees for errors. Any healthcare provider or healthcare facility that has or has had a contractual relationship with a plan or issuer to provide items or services under such plan or insurance coverage must also reimburse enrollees who relied on an incorrect provider directory and paid a provider bill in excess of the in-network cost sharing amount. Okay, so that covers the provider requirements in a little bit more detail. I will now just shift a bit to talk about the CMS and state and territory enforcement pieces. Under statute, CMS will only enforce a provision with respect to the applicable regulated parties if CMS determines that the state is not substantially enforcing that provision. So, for example, this can occur when a state does not have the authority to enforce or they have reached out to CMS and have requested for CMS to enforce for one reason or another. And this can be broken down provision by provision. So, prior to the beginning of this year, we did, we, CMS did publish kind of a list of the by state of the provisions that we will be in enforcing. And we can throw a few links into the chat, I guess, when we go back and forth on Q&A of some resources, but we can, we can share some information on that piece. But I can tell you that it is at this point as we get started in the enforcement sort of area, it's a, it's kind of a mixed, mixed bag. But CMS is enforcing for a number of states and territories, at least specifically the provider provisions. So, there are a number of resources I should have probably put on the top of this slide. The No Surprises Act, the CMS NSA website that went live in December that has a lot of provider facing resources around the No Surprises Act. But this slide outlines the rules of fact sheets, templates, and other resources for you to build on that, on those resources on the website, which is www.cms.gov backslash no surprises. And I'll put that in the chat in a few moments. And we are building on different sort of deeper dive training resources. So, some are, have been posted since we finalized this, this deck. So, there is, there is a deeper dive slide on other balanced billing protections on other No Surprises areas. And there's going to be a bunch different, a bunch of different deeper dive kind of trainings available to all of you. So, there are a number of terms that have been defined in the context of the rules and specific requirements that I just talked through. And these detailed definitions are all also posted on No Surprises Act. And you'll have access to this deck if you want to go through them more carefully. There are, they are sort of, you know, bucketed in these next few slides in definitions around out-of-network emergency services. And I know I talked a bunch about non-participating providers and participating health care facilities. This kind of breaks it down further. The other area that we talk about is providers network status changes and their definitions around continuity of care and conditions as it's outlined. Okay. So, with that, I know we're going to turn it back over. I think I'll turn it over to Eden in a moment to begin the facilitating of the Q&A portion of this session. I did just want to mention that we have a provider enforcement email address that we set up. We are receiving a whole a lot of questions from providers and otherwise that, you know, through this sort of forum, feel free to send some questions there. We are working our way through them. So, and our real goal is to take a lot of the different questions, categorize them, and pull them into frequently asked questions that we can post and make available to the provider community. So, I can also throw that in the chat as well. And it's on the deck that was shared with you. With that, I will turn it back over to Eden. Thank you, Sam. That was a wonderful presentation and you all may have seen in the chat, there are a lot of links populating in there. Sam's slide deck is actually linked in there. Go to the chat. Look for Lakeisha Mayo's name. She, that link that she posted in particular will give you Sam's slide deck. And then the subject matter experts from CMS have also posted additional links. So, we'll start off and if we could get, you know, for whoever's addressing any of the questions, we would love to have your camera on if you're able. We understand with the snowstorm sweeping through the country, some people's bandwidth might not be that great. Let's start with some, we've gotten a few questions about the good faith estimate. really the who, the what, the when, and the hows. So let me start with this question, and Erin, if you can direct it appropriately to your subject matter experts. What is the time frame for alerting patients of the cost? Does it have to be in writing or verbal? And how should it be documented? Yep. And I'm going to turn the good faith estimate questions over to my colleague, Jamie Hermanson and or Emily Ames. If you could take some of those questions. Sure. Hi, this is Jamie Hermanson, and I'm with the Consumer Support Group. In terms of the whether it needs to be in writing, the requirement is that the good faith estimate must be provided in writing. You can provide the good faith estimate information verbally, but in order to meet the requirements, it would also need to be provided in writing. If the individual requests it verbally, you can always do that. So and then can you repeat the? Sure, sure. Is there any in terms of providing it in writing? Are there any requirements around how it should be documented? Sure. We have provided specific information regarding the methods that the if it's provided electronically, it needs to be in a format that can be written, I mean, that can be both printed and saved. It can also be submitted through a patient portal. You know, those options are all available depending on the communications available to the provider, we would remind everyone of, you know, the various privacy requirements out there as well in terms of transmission of that information via email, I would say to or it could also be mailed to the individual or handed to them in person. Great. And so what is the timeframe around this? Is there a specific time parameters in terms of when they need to provide the good faith estimate? Sure. If the item or service is scheduled up to 10, within, you know, up to three days in advance, then the good faith estimate needs to be provided within one business day of receiving the of the scheduling or of the scheduling of the service. If the item or service is scheduled up to, you know, more than at least 10 days in advance, then the or if upon if the good faith estimate is requested, and without, without additional scheduling at the time, then the individual has three, you know, then the provider would provide the good faith estimate within three days, within three business days. Wonderful. So let's talk a little bit about responsibility. So and let's just use the example of screening colonoscopy. So which is obviously we're working with gastroenterologists here, who would be responsible for providing the good faith estimate? Is it the doctor's office who is scheduling say that that procedure that screening colonoscopy or the ambulatory surgery center where the procedure is being performed? I think they could depend, I would say in general, if the individual if the if the individual is working with the gastroenterologist office, and they're saying, Okay, we're going to go ahead and schedule this, typically, that would be that that would the gastroenterologist office would be considered the convening provider. But again, there could be circumstances where if the individual reached out to the ASC, or the you know, the facility where they were doing that, and they and the scheduling was happening from that side, then then they could potentially then the ASC could potentially be the convening provider. So it may just depend on the circumstances. Okay, so if that's a typical scenario, you all have kind of a help desk or a resource where they could they could reach out again, right to kind of walk through that scenario. Of course, no, you're always welcome to reach out to us anytime. Okay, wonderful. So the next question is, how do we provide a good faith estimate if we don't know a diagnosis code or billing codes prior to and they give the example of a colonoscopy screening? Well, we do a good faith estimate is required. But what we would say is if you're not, if you do not have information about you know, the diagnosis yet, you're not able to determine what that is, we know in screening services, that's, you know, that is always a challenge. What we would say is that a diagnosis code would not necessarily be required to be included if that information isn't necessarily available. So in the group, but the good faith estimate would be required. Okay, and what is the recommendation for establishing a good faith estimate for pathology, when the number of specimens and stains are unknown prior to the service? At the time when the, when the, when the service is scheduled, and this, you know, we know that the situation is typical with laboratory, with laboratory services. You know, we expect that the providers will be providing the best, you know, the estimate of the best information based on the information they have available, and the most accurate information that they have at the time. However, in circumstances where the actual bill charges, let's say there were additional, you know, specimens or stains that needed to, you know, or assays that needed to be run, you know, during that, during that particular lab service, if the actual bill charges end up exceeding $400, more than an individual may have the, you know, will then have the opportunity to choose to, to initiate the patient, the patient, I'm sorry, the provider patient dispute resolution process, and then they, the additional details can be discussed through that process. Okay, we've had a few on this topic come in through, come in through the Q&A as well. And I'm, give me one second, things are popping up on my screen left and right here. So what would be the requirement for the estimate if the patient is scheduled for a colonoscopy the next day? So I think you said three days before? If somebody is scheduled for a service less than three business days in advance, then a GFB would not, would not be required. And then another person is following up on the pathology. And they just said that they thought they didn't need to do this for pathology. But were you saying before that, that they do, just to get clarification? A laboratory test could be included as an item or service. So if they're being scheduled, if the pathology and the lab services are being scheduled in advance, or they're considered part of the period of care for other services, then a GFB would be required. Are in-network facilities required to provide good faith estimates? All guidance makes reference to self-pay and uninsured patients. I think just to get some clarification on the question, are they asking about situations where the individual is, you know, is enrolled in a plan or coverage and they're expecting to use that plan or coverage? I think you could maybe just make an assumption. All I have is this question. So if that's the, if that is the situation at this time, we are, we have not released regulations regarding good faith estimates for individuals that are insured and that are seeking to have claims submitted to their insurance in those circumstances. And so until that time, when our regulations have been promulgated on that, we are exercising our enforcement discretion and delaying implementation of those specific requirements. And so therefore the good faith estimate would not, is not required to be submitted to the planner insurer at this time. And what is your suggestion for providing a good faith estimate when we do not know what technique will be done prior to the procedure, such as the patient is seen for a colonoscopy, but then the provider needs to do a biopsy or other technique? Sure. And we know this is a common, you know, common situation where it starts out as screening and then we find out that they, that a polyp may need to be removed in those circumstances. So those, those situations do come up. I would say it's the same situation as with the, with pathology. So if we end up discovering that the, you know, again, you're going to be providing the good faith estimate based on the most accurate information that you have available at the time of scheduling. However, at the, after if, again, if the bill charges and, you know, the actual bill charges and exceed $400 and the individual may end up choosing to initiate the patient provider dispute resolution process. Okay. And would, would a self-pay agreement be the same as a good faith estimate? I'm sorry, can you clarify a self-pay agreement? That is what they, you know, somebody else asked about what elements need to be provided in a good faith estimate. So maybe that'll help answer that question as well. Sure. There are a number of elements that need to be included in a good faith estimate. We include, and generally speaking, let me, because the, let me go ahead and if somebody could submit that question, I can take it back and we can respond more comprehensively in writing. Yeah. And just as, oh, yep, go ahead, Erin. Sorry. I just want to chime in here. What I've seen with practices, again, the good faith estimate has certain elements that you have to include. But I've also seen questions come in before the call about customizable templates for the various notices and the good faith estimates. So what I have seen other practice areas do is provide one, two members that make sense for your practices, but inclusive of those required elements. And so while we don't provide customizable templates, that is something I have seen other memberships do just that are relevant and germane to your practices, but of course, including those required elements. And I think about the self-pay, I agree submitting it in writing, but in general, I think, you know, it, we don't know what your self-pay agreements are, look like. So it's hard to say, but your good faith estimate would still be required with the self, in addition to the self-pay agreement, and it should include those required elements that are outlined in our, on the fact sheet that I posted earlier in the model good faith estimate. So I just wanted to take a stab at that and also try to weave it in with a question that I've seen previously. Wonderful. Thank you, Erin. And I think the other thing just to add to that as well is that we did provide a model notice. And while it is, the model notice is not, it's not required to be used, but it is out there as an availability. So it may be that different, you know, providers have, you know, have things where they may just need to, you know, make minor modifications to forms that they already have available. So we really wanted to provide that flexibility to practices so that they knew, so that they have the ability to, to use, you know, items that they already have with modifications to bring them into compliance with the, you know, with the good faith estimate requirements. So those options are available. Okay. So we're going to tackle maybe two more on the good faith estimate, and then we're going to move to just some disclosures. So the first one, just to clarify, a good faith estimate is required when services are required, when services are provided by an out of network provider, or when the patient is uninsured or self pay. Is that correct? So again, I'll just read it again if you need that. For clarification, I think they're giving really three scenarios. A good faith estimate is required when services are required, when services are provided by an out of network provider, or when the patient is uninsured or self pay. Is that correct? So the key factor for, for all of these scenarios is number one, the determination of whether or not the individual is insured and seeking to file, seeking to have a claim filed with their insurance. So if the individual is, is either uninsured or not seeking to have and or not seeking to have a claim filed with their insurance against self pay, then they then a GFE would be required to be provided for items and services scheduled or upon or if a GFE is requested for items and services expected to be scheduled three days, at least three days in advance. And then the last, so I think that way regarding the network status, again, if the person is, you know, has insurance, and they are expecting to have the claims filed to their insurance, we are still in the process of developing regulations for that and more information will be available once those regulations have been have been promulgated. Okay, we will go ahead and sorry, if it's okay for me to just jump in. This is Lindsay Marshall, and I just wanted to clarify, because I think that this question may be picking up on some confusion we sometimes hear. There is a Jamie has done an amazing job talking about the different requirements for the good faith estimate that has to be provided to uninsured and self pay individuals. There is a separate requirement to provide a good faith estimate as part of the notice and consent procedures if somebody if a provider facility wants an individual to ask an individual to waive their balance billing protection. And that's when you might the out of network piece might come into play. I just wanted to jump in to highlight that distinction because everything that Jamie has gone through is about the separate, the good faith estimate that stands alone. Then there are those separate requirements related to the notice and consent to waive balance billing. Under those rules, we do say that the provider or facility should look to the standards that they're using for calculating a good faith estimate under the requirements Jamie's talked about. We wouldn't want, you know, a provider or a facility to be just using totally different processes for considering what services to list in the good faith estimates under these different requirements. But they are distinct requirements. And so there are some circumstances in which an out of network provider would be providing a good faith estimate, but it would only be as part of that notice and consent process. So I just wanted to underscore that point. Wonderful. Thank you. We still are getting a lot of questions on good faith estimate. I just want to move to disclosures for a little bit. And if time permitting, we'll go back to good faith estimate. We will produce a frequently asked questions. We'll work with CMS for anything that does not get answered. So please know that your questions are not going into a black hole. We will get them answered. Moving just to the topic of disclosures, please provide or direct me to forms for the office and those forms that must be given to patients and explain them. I'm happy to take this one. Erin, maybe while I talk, if you could drop the link into the chat. So on this question, I believe it's about the disclosure requirement regarding balanced billing protections. And so there's a requirement that Sam talked about that a provider and facility needs to notify or disclose information about the balanced billing protection. We have a model disclosure form, and Erin is posting the link to where those can be found in the chat. That is not a mandatory form. You need to hit on the elements, but could use a different format if you'd like. One thing I do want to highlight is that it does require some tailoring to the particular state that you're practicing in. So if there are applicable state balanced billing rules, you're going to need to modify that form. But the model that we provide describes the federal requirements and includes a place where the state information could be inserted. We are also in the process of the way the federal procedures work. We released this initially for a six-month period, and then we were asked, I'm sorry, my internet seems to have just kicked me off Zoom. Can you all hear me? Yes, we can still hear you. You can go ahead and turn off your camera. Maybe that'll help. Okay, cool. So we are, we may be releasing some updated forms, but the ones that are posted could still be used at that point. So our next question is, is it legal to collect when a patient signs an advanced beneficiary notice form? So one thing I wanted to clarify is my understanding, and I think this is what the question is about, is that they refer to a form that is used in Medicare. These protections do not apply in Medicare, and this form is not required to be provided to Medicare beneficiaries unless they're enrolled in a group health plan or they have dual enrollment. What must be posted in the lobby of our office? Where can a model disclosure be found? Sure. So the same disclosure form that I just talked about could be modified to be posted in the lobby. The requirement is that a sign or information must be posted prominently in the provider facility's location. Okay. And is there a site where we can find customizable templates? So this person actually commented just the amount of information is so daunting. So is there anything that's customizable that they can download from CMS, or I think, Erin, you spoke to some societies that are producing these? Yeah. So I've seen, and going back to what Jamie said to you in the links for the forms I've posted a couple times in the chats, that I've seen practices just come up with a suggestion of, you know, what your particular practice area is that you could use. So based on your knowledge of, like, we know these are common circumstances per US DPF on colonoscopies, right? And, like, here's how you would list this in a good faith estimate. And so you can look at our form, which I posted in the link, the various forms. You know, I'm just kind of spitballing here, but, like, download it, and then come up with maybe a consensus of how you'd want a template to look for your practice with those required elements in it. So we don't do the customization for you, but I think you could, like, take that form, cut and paste it into your own template with the requirements, of course, embedded in whatever that customizable template. So, like, for mental health professionals, they have made suggestions on how that should look for their particular practice area, whether it's psychiatry, psychology. And so, you know, that would really be incumbent upon, however, the membership or the practice areas wanted to come up with those. But I have seen... The other area... Sorry, go ahead, Erin. Yeah, go ahead, Lindsay. The other area that providers might want to check are states, because some states may be developing language that could be used for the state-specific requirements. Yes. Well, our next question is, are disclosures the responsibility of the physician practice, the ambulatory surgery center, or both? For example, when a physician is referring a patient to an ambulatory surgery center for a procedure. Sure. So let me break that down a little bit. There are... To talk about kind of the three different ways that disclosures have to be provided, because the answer differs a little here. The requirement to post on the website and to post prominently in your location are, you know, on both the provider and the facility. So if you're a provider who only practices in a facility, that may be overlapping there. The requirement to provide to the individual is technically on both the provider and the facility. However, the rules recognize that overwhelming consumers with paperwork is not ideal. And we realize it's not really necessary if somebody walks into a facility like an ambulatory surgical center for you, the doctor, to give it to them and the front desk to give it to them. And so the rules provide some flexibility here where the provider and facility can work together to ensure that the facility is providing the notice on behalf of the provider. We do require that that be agreed to in a written agreement. So it's not enough just to assume that the facility will be providing it and consider yourself off the hook. But as long as there's some written agreement in place that the facility will provide it on behalf of the provider, that will meet the requirement for the notice, the disclosure provided directly to the consumer. Moving to a more general question, are insurance payers required to send explanation of benefits and remit to providers, specifically they're saying to the providers, not the patients, for emergency and non-emergency services? If that question's not clear, we can maybe follow up with the person. Yeah, I think that would be good. Okay. We'll follow up with the submitter on that one and get back with you. How does one find state requirements and fee schedules for rates for out-of-network in these cases? This particular person is writing from Oregon. I'm not quite sure exactly the focus of this question. There are, as Pam outlined, the out-of-network rate may be determined in one of three ways. It could be through the specified state law, an all-payer model agreement, or if neither of those exist, it would be, or neither of those is applicable, it would be through the federal, open negotiation and then a federal independent dispute resolution process. We have posted on our website, and unfortunately I don't have the information, the link handy, which applies in which state, so that information is on our website. In terms of a fee schedule, though, I think the only time that would come into play is if the state has a specified state law that uses a fee schedule, or if there's an all-payer model agreement in place that uses a fee schedule, so that would really be dependent on the particular state. So just to kind of sum up, I think that you could go to our website to figure out if one of those, if you're in a category, if you're in a state and a category that a specified state law or all-payer model agreement fits. If you're not, and you're in the bucket where the network rate is defined through open negotiation and the federal independent dispute resolution process, that information won't be relevant. And if you are potentially in a world where a specified state law or all-payer model agreement applies, you'd have to go to the state. Yeah, and Lindsay, thank you so much, Lindsay Murtaugh, and then also Lindsay Robbins posted the link to the specific Oregon letter, enforcement letter. Wonderful, thank you. And we will, hopefully folks are getting those links, we're getting some messages that some people are having some problems. We will kind of aggregate all this information, put it all together, and we'll include all these links again that are popping up in the chat. So if you can get them in the chat, great. If you're having a problem with it, know that, again, this information is not going into a black hole. We'll put it together, package it back together for you so that you have it as well. So let me get back to good faith estimate here. If the ASC provides a good faith estimate that includes ancillary services like an outside pathology lab, and the cost ends up being more than $400 for pathology, who goes to IDR, the ASC or pathologist or pathology lab? The good faith estimates would be organized and the expected charges for each provider facility would be grouped by that provider facility. So the individual that would be potentially going to IDR, it would be by provider. So it could be if it's related to lab-related services, then it would be a laboratory, etc. So each provider that is listed and represented in the good faith estimate would independently be responsible for their particular items or services if the individual avails themselves of the patient provider dispute resolution process. Thank you. So we have a few more minutes. I'm going to try and sneak in a few more questions since we have CMS on the line before we close out for the day. First we have in the preliminary info, it was communicated that good faith estimates for ancillary services were not required until 2023. Has that changed? And good faith estimates for pathology and anesthesia services are required as part of the good faith estimate from the GI provider and or endoscopy center. Sure. Regarding the, regarding whether or not additional the ancillary services furnished in conjunction with the provider, those additional services, we have provided enforcement discretion regarding and, you know, and some flexibility for calendar year 2022. And during that time, we understand that it's, that it may take some time to establish, you know, communication mechanisms between providers and facilities, as well as, you know, co-providers and co-facilities and the convening providers. And so we're, we're allowing and providing some flexibility for this first year in order to have those established. So that enforcement discretion is that if we, if the, we would not take any action, if the good faith estimate does not include information from co-provider, co-providers or facilities during calendar year 2022, but we do want to emphasize that there's nothing that would stop any, that would stop or prevent anybody from including those, those estimates and information, that good faith estimate information in the good faith estimate that's provided, if that information is included in calendar year 2022, if you already have those communications mechanisms established, we, you know, highly encourage you to, to start including that information in, but we did want to recognize that, that, that, that, that those, those circumstances are out there and providers may need additional time. Wonderful. You know, we're coming to the top of the hour, Erin, let me throw it over to you. Do you have any final comments from CMS or? Yeah, no, I just want to thank you all again for the invitation, my colleagues, Jamie and Lindsay, and also, and Sam for the presentation, others have been chiming in here. And I think as you can see, we are here as a resource and, and closing, I just want to say that, you know, this is historic consumer protections that are in place now, and we appreciate you all doing all of your parts to, to meet those protect consumers from surprise bills. So thank you so much for your thoughtful questions and participation. Thank you. Thank you, Erin. And to everyone at CMS, we have come to the close of this presentation. I'd like to thank CMS for taking the time to answer our questions today. As a reminder, we will be placing the webinar recording in ASG's online learning platform, GILeap, and we'll send you an email when it is available. And we'll have some other resources in there too, those handouts that if you weren't able to download them, we're going to, GILeap is a great place where we can kind of centralize and have the recording and all the materials for you. This concludes the presentation on new surprise billing regulations. Please take the brief survey at the conclusion of this webinar. We hope this information is useful to you and your practice. Thank you.

ASG sponsored webinar

surprise billing regulations

No Surprises Act

patient protection

out-of-network care

balanced billing protection disclosures

notice and consent

good faith estimates

ambulatory endoscopy centers