If a family does not have insurance, or the family won’t be using insurance for an encounter, then a pediatric practices needs to provide a “Good Faith Estimate” for the cost of care when an encounter is scheduled more than 3 days in advance.
This requirement came into effect on January 1st, 2022 as part of the “No Surprises Act”, and it aims to reduce the likelihood of a family receiving an unexpected medical bill.
Apply the Good Faith Estimate Rules for Pediatrics
Under what circumstances would a pediatric practice need to provide a Good Faith Estimate, and what should the estimate include?
Review the Types of Encounters You Schedule
Your practice schedules a variety of encounters, including physicals or “well visits”, next-day or same-day sick appointments, rechecks, and various consultations.
A typical pediatric practice should be prepared to offer Good Faith Estimates for their well visits, recheck visits, or consults—any appointment that would likely be scheduled more than three days in advance. It is unlikely you will need to provide a GFE for typical “sick” encounters, but you may wish to create one anyway for less-common circumstances.
Develop Estimates That Are Within $400
When you provide a Good Faith Estimate, it should declare the expected cost of services typically performed during the type of encounter, with an accuracy within $400.
For example, your Well Visit Good Faith Estimate might list expected amounts for a well visit and immunization administrations for each age, including amounts for common screenings.
While you are not required to detail the individual costs associated with an encounter, your practice may choose to list common procedures and prices to help the family understand what is included in the GFE.
Always Verify Payment Information When You Schedule
Medical professionals are not required to provide GFEs if the patient or family intends to bill insurance for the encounter, or if the practice will bill an insurance payer on behalf of the family.
Therefore, in addition to developing a GFE form for certain encounter types, your practice should review how you schedule appointments.
Whenever you schedule any encounter, your practice should:
- Ask the patient or family how the encounter’s charges will be paid
- Collect or update the patient’s insurance information
- Provide a GFE if the encounter will not be paid by insurance
PCC software includes customizable tools that can help your practice complete these tasks, such as Clinical Alerts which can appear during scheduling, the customizable Patient Details ribbon, and the ability to check insurance eligibility at any time (including a tool for reviewing eligibility for all scheduled patients). Contact PCC Support for help getting started with any of these tools.
No Insurance, Or Not Using Insurance For a Given Encounter: When a patient or family indicates that they do not have insurance, or that they do not intend to bill insurance for a specific encounter, and the appointment is scheduled three or more days in advance, you should provide a Good Faith Estimate that lists the expected charges with an accuracy within $400.
Develop a Workflow for Sending out GFEs
When your practice knows that a family will not be paying for an encounter with insurance, you should provide them with a Good Faith Estimate within three days of scheduling the appointment.
Your practice could use various methods to accomplish this. You can produce the required form immediately after you schedule the appointment, using the Forms component, and then deliver it using the patient portal.
If the family does not have a portal account, you can generate a PDF and use email or physical mail. You can work with PCC Support to adjust your forms and customize reports to meet this need.
Create Good Faith Estimate Forms
Your practice can develop quick Good Faith Estimate forms to help you provide a Good Faith Estimate whenever it is needed. For example, you could create a form letter that lists your GFEs for each type of encounter, and then send that form to families through the Patient Portal.
VFC and TOS Cash Discounts: If your practice administers VFC or other reduced-rate immunizations, you may wish to account for that difference in your GFEs. Similarly, if your practice offers a discount for payment received at time of service, you can include that information on your GFE forms.
While your practice is not required to provide an itemized charge list, many practices are choosing to do so in order to define the amounts included in the Good Faith Estimate.
Olney Pediatrics in Maryland and North Augusta Pediatrics has shared a sample Well Visit form (charge amounts have been removed for this image), which allows them to quickly create a GFE by checking off the details for a scheduled encounter and entering a total:
You can download a Microsoft Word file version for use at your practice.
The AAP has also created several sample forms:
In order to provide an accurate GFE for lab work that may occur outside of your practice, you may want to contact your lab companies. The AAP created a sample letter:
You can access the above AAP’s materials through the SOAPM website.
Contact PCC Support for help setting up your Good Faith Estimate forms.