Beginning January 1, 2022, if you’re uninsured, you pay for health care bills yourself (don’t have your claims submitted to your health plan), or if you see an Out of Network (OON) provider, you have financial protections afforded to you by the No surprise Billing Act of 2022.
If you are uninsured, pay for health care bills yourself or are OON, health care providers and facilities must provide you with an estimate of expected charges before you get an item or service. This is called a good faith estimate (GFE). Providers and facilities must provide you with a good faith estimate if you request one, or after you have scheduled an item or service. It should include expected charges for the primary item or service you are getting, and any other items or services that are provided as part of the same scheduled experience. The provider or facility you contact for a good faith estimate must provide a list of all items and services associated with your care. In 2022, the good faith estimate is not required to include items and services provided to you by another provider or facility, but you can also ask these providers or facilities for a separate good faith estimate. In 2023, the provider or facility you contact will be required to provide co-provider or co-facility cost information in the good faith estimate.
For example, if you are having surgery in 2022, the good faith estimate would include the cost of the surgery but would not include the cost of any lab services or anesthesia used. Additionally, separately scheduled services may not be included in the good faith estimate even if they are related to your surgery. These could include pre-surgery appointments or physical therapy in the weeks before or after the surgery. Providers and facilities must:
- Provide the good faith estimate before an item or service is scheduled, within certain timeframes.
- Offer an itemized list of each item or service, grouped by the provider or facility offering care. Each item or service must have specific details, like the health care code assigned to it and the expected charge.
- Explain the good faith estimate to you over the phone or in-person if you request it, and then follow up with a written (paper or electronic) estimate.
- Provide the good faith estimate in a way that’s accessible to you.
Once you receive a good faith estimate from your provider or facility, be sure to keep it in a safe place so you can compare it to any bills you get later. If you have had your service and find that the billed amount is at least $400 above the good faith estimate, you may be eligible to start a patient-provider dispute resolution process. We ask that patients contact our office directly prior to initiating a formal dispute resolution. You do not forfeit your rights to dispute a resolution by doing so. This will save time and aggravation for our patients by working with them directly to resolve these issues without the need of a third party. If we cannot come to a resolution independently, you are still within your rights to file for dispute resolution. Learn more about the dispute resolution process, including eligibility requirements and what information or documents you need to start a dispute.
For questions or more information about your right to a Good Faith Estimate, the No Surprises Act, or payment disputes, visit www.cms.gov/nosurprises or call (800)985-3059.
If we are not in your insurance company’s network, your care will be deemed Out of Network. In this case, we are required to notify you of that fact. The No Surprise Billing act requires your provider disclose this to you prior to you receiving care or treatment. In addition to notification, we must attain a signature from you acknowledging that you are aware of the providers’ out of network status.
Choosing to see an Out of Network provider may affect your ability to attain care at the lowest available cost share to you. We are also required to inform you that you may be responsible for the difference between your insurance company’s payable amount and the providers billed charge. By choosing to seek care from an out of network provider you are acknowledging that such payments may not be eligible to accrue toward meeting some or any of your insurance company limitations, such as out of network deductibles or out of pocket limits.
“I have been going to Willamette ENT on and off for most of my life. The staff is always so friendly, and the doctors and nurses show a lot of care and compassion!”