GFEs and AEOBs Could be a Real SOB

The No Surprises Act (NSA) went into effect nearly a year ago and certain aspects regarding its implementation remain up in the air. In particular, where ownership should fall with regard to the more laborious tasks associated with Good Faith Estimates (GFE) and Advanced Explanation of Benefits (AEOB), as well as how the exchange of data can be done efficiently while conforming with patient protections. 

A Little Background

For those unaware, a GFE is a list of cost estimates associated with a scheduled service or procedure to be provided for an uninsured or self-pay patient. Sounds pretty straight forward, no? Not really. The convening provider is responsible for compiling pricing estimates for any resource that might “reasonably” be used during that episode of care. And It isn’t simply the pricing but also the inclusion of all associated diagnoses and service codes, which may not be fully determined at scheduling. This will require the coordination of multiple departments that are already stretched thin with staffing shortages and an already heavy workload.  

As if sourcing this info internally wasn’t enough, the convening provider is responsible for coordinating these same estimates from the co-providers that will be involved in the scheduled service/procedure. The information for these estimates needs to be gathered, documented and presented to the patient within 1-3 days of scheduling said appointment or request for an estimate is made.  

Timeliness of providing estimates isn’t the only stressor associated with GFEs but level of accuracy will also be top of mind for administrators responsible for compiling estimates. Any estimate provided with a $400 variance could end up being held in the PPDR process. The risk for the hospitals could be lost revenue for some of the services provided, but will definitely lead to delays in collection of all revenue for that episode of care. Again, admin teams already stretched thin better be accurate to every single line item or they risk losses and timeliness of collections. 

Well at least it’s not for all patients, right? Actually, another protection currently built into the NSA is the requirement that third party payers provide advanced explanation of benefits to their members ahead of scheduled procedures. To this, the insurance companies say, “we need accurate cost estimates.” Cue all eyes collectively turning back to the provider side of this consumer protection party. This ask is essentially putting onus on the providers to complete a pre-claim process where GFEs are given to payers so they can give AEOBs to their members. Basically, estimates compiled for all scheduled services.  

An Opportunity To Be Heard

The agencies charged with overseeing the rollout of these NSA protections are aware of the monumental effort and interoperability that will be required, which is why timelines have been adjusted. These agencies are also looking for feedback from the various stakeholders within healthcare, which can be submitted here:      

The following are just a handful of questions you can provide professional perspective on:

  • Asking payers if they believe diagnosis codes are needed for an AEOB? Could they easily determine contracted rates, coverage levels and coverage of specific services without diagnosis codes? 
  • Asking providers how much of an added burden determining the following would be:
    • If patient is uninsured, self-pay or enrolled in a plan or coverage? 
    • Each item or service is covered within plan?  
    • Does patient have multiple coverage?  
  • Asking providers if relying on a patient’s word to determine coverage would alleviate added work? What might the implications of this be?  
  • Asking providers to estimate their costs for an investment in a standards-based technology platform that would provide real time data exchange for AEOBs and GFEs via a vendor? What would the cost be for in-house development?  
  • What other program changes could be made that would support providers with exchanging needed info/data for GFEs and AEOBs? 

So, What Now?

There’s a good chance that the finalized version of GFE and AEOB requirements will be less burdensome compared to their present guidelines, but don’t leave it to chance. Make sure your voice is heard.  

At the end of the day, the NSA is undoubtedly going to pile on more work for healthcare administrative teams already stretched thin. If you find your team is running into coverage gaps due to added steps in the revenue cycle spectrum, give HCM a call to explore how we can bridge those gaps.

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