No Surprises Act of 2021

No Surprises Act implementation — Borrowed from the Pennsylvania Psychological Association

As part of the No Surprises Act of 2021, health care providers will be required by law to give a good faith estimates of costs for services they offer when scheduling care or when the patient requests an estimate. This is an evolving issue, and you can expect additional information in the New Year. PPA and APA are working diligently to try to understand the nuances of this new law. As each state implements the law, more information will become available, and we will get it to you as quickly as possible. 

There has been much speculation and misunderstanding related to the new law, and this page attempts to provide clarity. Please read it carefully.

Applicability: One of the primary misunderstandings on the PPA Listserv recently has been around who is impacted by the law. It is important to understand that the No Surprises Act applies to ALL health care providers acting under the scope of their professional license, not only psychologists. Uninsured and self-pay patients can anticipate receiving similar good faith estimates from all physicians, dentists, etc. in the new year. 

• Currently, good faith estimates need to be provided to patients/prospective patients who are uninsured or plan to self-pay. There will be further guidance in the future regarding applicability for patients using insurance.
• The rule does not distinguish between current and future patients. Therefore, the disclosure requirements likely apply to current uninsured/self-pay patients as well, and they should be provided with an estimate as well.

Timing: The good faith estimate of expected charges must be provided within specific timeframes.

*A new estimate must be provided within the above timeframes if the patient reschedules.

Content: The good faith estimate must include the following:

• The patient’s name and date of birth
• A description of the primary item or service being furnished to the patient (and if applicable, the date the primary item or service is scheduled)
• An itemized list of items or services that are “reasonably expected” to be furnished
• Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service
• The name, National Provider Identifier, and Tax Identification Number (TIN) of each provider or facility represented in the good faith estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished. (APA recommends using a business TIN rather than your SSN)
• A list of items or services that the provider or convening facility (the provider or facility that handles the scheduling of the service) anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service
• Specified disclaimers: The language for these disclaimers was provided by CMS and is included in Appendix A here.

Frequently Asked Questions

Q: How do I provide a diagnosis code for someone I haven’t met?  

For most new patients you can just indicate “TBD” under the “diagnosis code” section. If you later assign a diagnosis to that patient, you can update this information in future Estimates provided to the patient.  Please also remember that there are ICD-10 Z-codes that can be used in situations where the patient does not meet criteria for other diagnoses (e.g., Z63.0 Problems in relationship with spouse or partner, or Z65.9 Unspecified problem related to unspecified psychosocial circumstances). 

Q: How do I handle providing the estimate when the patient is a child?

The good faith estimate can be treated similarly to other informed consent documents (i.e., provided to parents of patients 13 years old or under, and to the person consenting to treatment for patients 14-17).

Q: What if I believe different modalities will be needed?

The good faith estimate should include whichever CPT codes you believe will be included in treatment, including individual therapy, group therapy, diagnostic interview, testing, etc. 

Q: Is it enough to just provide your rates per session or do you have to give your best estimate of the number of sessions or frequency in writing as well?

It is not enough to just provide your rates per session to a new or established patient. The good faith estimate should include the rates per session of the service(s) you anticipate providing to the patient, as well as the projected number and frequency of sessions. If you anticipate providing the same services to the patient at the same frequency over a period of time, you may provide a single Estimate to that patient for all those services, so long as: (1) the Estimate includes, in a clear and understandable manner, the “expected scope of the recurring primary items or services (such as timeframes, frequency, and total number of recurring items or services)”; and (2) the Estimate can only include recurring services that are expected to be provided within the next 12 months.

Q: What do I do if a patient later requires more or less intensive treatment or services?

You should update the information contained in the good faith estimate previously provided to that patient to reflect any significant changes the expected cost of services to the patient, (e.g., patient originally came in with a mild diagnosis that you expected would merit 8-10 sessions, but subsequent trauma or discovery of a more serious diagnosis causes you to shift to a much longer expected course of treatment). It is especially important to update your Estimate if it goes up and creates the risk of exceeding your original Estimate.