Good morning, everyone. I'm Lindsay Kaysen with the Georgia Hospital Association, and we are very pleased to be your host for today. On behalf of GHA, we welcome you to today's webinar covering the No Surprises and Surprise Billing Consumer Acts. And before we begin with this morning's presentation, I would like to take just a moment to draw your attention to a few items of note. As you're joining in with us this morning, you may notice that all participant lines are muted. And while those lines will remain muted throughout the duration of today's presentation, there are several ways that we do invite you to interact and engage with us today. So if you'll take just a moment and hover your mouse over the bottom of your Zoom window, you should see those options available to you there. First, if at any point throughout the presentation, you do experience issues with audio or video, we encourage you to select that option to raise your hand, or you can always type a comment in the chat, and we'll reach back out to you to help resolve any technical issues that you may be experiencing. Also throughout this morning's presentation, we will have moments of Q&A. So again, at the bottom of your Zoom window, you should see that option that says Q&A. You can go ahead and type in your questions there as they arise. And then at the appropriate time, we will take those questions in the order that they have been received. And a nice feature of the Q&A is that you can choose to submit those questions anonymously. So please don't be afraid to ask. And lastly, today's session is being recorded, and you all should receive an email tomorrow around this same time with a link to view that recording, and that link will be available for 60 days. If for some reason that email does go to your spam folder, you can always go back and use the same Zoom link to access the recording that you also used to access today's live session. And now I would like to introduce our speakers to begin today's presentation. Ms. Kathy Reap has more than three decades of leadership experience in the health care industry. Her hospital setting expertise is in compliance, financial advisory, reimbursement, and managed care. Kathy has helped with Medicare, Medicaid, workers' compensation, reimbursement, and many other complex programs and issues. She's a thought leader and provider educator, helping hospitals navigate regulations and the impact of change. Prior to joining PYA, Kathy served as Vice President of Financial Services with the Florida Hospital Association. She also held longtime positions as well as roles working in patients' business, internal audit, systems management, diagnostic-related group management, and as a reimbursement director. And then Carrie Conley is General Counsel and Senior Vice President of Health Care Policy for the Georgia Hospital Association. In her role at GHA, Ms. Conley advocates on behalf of hospital members at all levels and branches of state and federal government, conducts regular meetings of hospital compliance officers and in-house legal counsel, and acts as a resource and liaison for hospital members on state regulatory matters as well as Medicare and Medicaid compliance issues. She's a member of the State Bar of Georgia, the Georgia Academy of Health Care Attorneys, and the American Health Lawyers Association. And then Ms. Donna Hatcher is the Vice President of Managed Care Policy at the Georgia Hospital Association, where she works with regulatory agencies, managed care companies, and other payers on behalf of GHA members. Donna came to GHA from Children's Healthcare of Atlanta, where she was responsible for payer contracting and communications for three hospitals, ambulatory surgery centers, other ancillary centers, and several hundred professional service providers. Donna is a nurse by training and has previously worked as a physician practice management consultant, network development manager for a managed care plan, and a public health nurse practitioner. And now I would like to turn the program over to Donna to get us started. Donna? Thanks, Lindsay, and good morning, everyone. We're really glad you could join us today. I'm going to take just a minute to talk about the Georgia law, the Surprise Billing and Consumer Protection Act. Our main focus today is the No Surprises Act, but there is, or I should say, the rules for the No Surprises Act do acknowledge that states have different surprise billing requirements, and there are ways in which the intent is to work with those. And so I'm just going to give a quick overview of the Georgia law. There's a link on the presentation when you get that if you want to look at the entire bill. The Georgia law was effective January 1st of last year, 2021, so most of you are probably pretty familiar. It applies to fully insured plans licensed in Georgia, which includes most of the exchange plans, and it also applies to state health benefit plan and board of regents. So this is the case with most Georgia insurance law. State health benefit plan and board of regents aren't under the authority of the commissioner of insurance, but it is not uncommon for legislation to include those in these kinds of rules that are passed. The Georgia law does not apply to limited benefit plans, air ambulance, workers' comp, Medicare, Medicaid, out-of-state plans, or self-insured plans. However, there is an option for ERISA plans to opt in to be included under this plan. Kathy, can we go to the next slide, please? Thank you. Back one. Okay, one more. So thank you. So like most surprise billing laws, the Georgia Consumer Protection Act is intended to protect consumers from unexpected bills for two kinds of services. One is out-of-network emergency services, and that applies to both facilities and providers. And out-of-network non-emergency services that are provided at an in-network facility. And what that means is that if a patient believes they are obtaining in-network services because they go to an in-network hospital or ambulatory surgery center, birthing center, et cetera, then that, you know, most of the time they expect that all of the physicians that treat them, including those that they don't select, specialties like anesthesiology or pathology, radiology, generally they expect those physicians to be in-network too. And of course, we all know that that's not always the case. And so the protections here are to prevent those surprise billings. The Georgia law doesn't address post-stabilization services and there has been some confusion around that. And there's actually a bill pending in the session right now that would address that. Of course, it's early, it hasn't been passed yet, but we're hopeful that that will be clarified soon. The act requires that insurers pay providers the greater of three different amounts. The first is the 2017 in-network amount paid by all of the eligible insurers. It does have a provision to update that annually, but it starts at the 2017 amount. Or the most recent contract amount for providers that have been in-network with the plan in the past, or a higher amount that the insurer decides is appropriate. So it's the greater of those three. On the other side, facilities and providers have to accept the patient's in-network cost share amount and cannot balance bill. So in that way, that's a big change. The biggest change for us on the facility and provider side is that the in-network amount can be collected from patients, but otherwise they are removed from any disputes about payment. It doesn't apply if a patient chooses to receive out-of-network services, as long as they provide oral and written consent. And when that is scheduled ahead of time, an estimate of the cost has to be included in the consent. That would cover situations, for example, if a patient wants an out-of-network position or an out-of-network hospital understanding that their cost shares are going to be higher. Next slide, please, Kathy. I'm not gonna talk too much about the dispute resolution process, but I wanted to hit a few high points here, and then we're gonna talk more about it later after Kathy talks about the federal process so we can highlight the differences. A few things to note, though, are that first of all, an out-of-network provider or facility that thinks the payment is insufficient can request arbitration within 30 days of receipt of the payment. And that request can cover either a single patient with a single service, a single patient with multiple services, multiple patients with a single service, or multiple substantially similar services in the same specialty on multiple patients. That's a mouthful, but there are different ways you can consolidate claims to submit one request. The insurance commissioner can dismiss a request if it's related or if it is a dispute with a plan over which the department does not have authority, and that includes ERISA plans, except, as I mentioned before, those that may have opted in. We are not aware of any that have opted in at this point. Let's see. Actually, this second bullet could have been updated yesterday, as a matter of fact, but there are some actions that are pending in the courts on state and federal levels, and there was a big decision yesterday for the No Surprises Act, and I'm sure Kathy's gonna talk about. It is also, the independent dispute resolution process is also not applicable for any binding claims resolution process that was entered into before July 1st of 2021. And with that, Kathy, I'm gonna toss it over to you. Thanks, Donna, and I just wanna say that I appreciate you going ahead and answering the question I was going to ask about whether or not any ERISA plans had opted in. I just wonder what will happen ultimately if they decide that the Georgia law is better than the federal law. So we'll kind of keep an eye on that. From the No Surprises Act, the law that was passed as a part of the Consolidated Appropriations Act at the, I guess, Consolidated Appropriations Act of 2021, there are two main provisions that we're gonna talk about today, and we're gonna pause at one point and take some questions and then do some more a little bit later. But first of all, we're looking at regulations that were issued in July and in October of last year. However, these were both interim final rules. That means they are effective, but it also means that they were open for comment, but we haven't had any responses to comment. So we are operating on what was the expectation of this is how we're going to do things. I do have a feeling, and particularly as Donna intimated, based upon some court decisions in the last day or so, we are going to have to see some changes to some of these rules that have come out. So stay tuned for more information on that. But the rules were effective January 1, 2022. So now we're approaching the end of February. So you've had almost 60 days of experience, although I'm not sure a lot of people really understand what all is implied in this. And I will give you a couple of tales that maybe will tell you even plans don't know what is entailed. So stay tuned. The two provisions that we're going to focus on today, first of all, is the provision that prohibits surprise billing. And when I say surprise billing, I want to say, and I probably will before we're done, use the term balance billing. I don't mean you can't bill a patient for their out-of-pocket liability. What I'm saying is that you cannot bill a patient for any more than their out-of-pocket liability if this is an emergency service, or if they have gone and they have gone out of network, or if they are dealing with a practitioner in network facility. So we'll go through those details, but please recognize I'm not saying you can't bill a patient for their actual liability. The other provision that we're going to focus on is a requirement to give self-pay patients a good faith estimate of the charges that they're going to be responsible for paying. That too was effective January 1, 2022. So let's get started with the provisions related to surprise billing. First, once we get through these, we're going to have Donna kind of jump in and give a little bit more Georgia insight, and then we'll take some questions on surprise billing. So the provisions related to surprise billing apply to, and I have to say this was a difficult rule for me to read because I'm so used to the term provider, meaning a hospital or an ambulatory surgical center, but all of a sudden now a facility is the hospital, a critical access hospital, a free scanning ED, an ASC, and it's also air ambulance. So we're dealing with facilities and providers. Providers are going to be the practitioners that furnish services in facilities. Under the No Surprises Act and the provisions related to balance billing, the rules are not applicable to physicians providing services in their offices. Now that will not be true when I get to the discussion of good faith estimates. So for now, what we're talking about under the balance billing, no surprises legislation, this is not applicable to services provided in a physician's office, but only when he is providing services at a facility. And again, a facility is a hospital, a critical access hospital, a freestanding ED, an ASC, and also applicable to air ambulance. There is a committee that has been appointed within CMS that is looking at applicability to ground ambulance. We might see some recommendations for that come out at some point in time. Gut feel is from a consumer perspective. They would like to see this expanded to include ground ambulance from a ground ambulance provider perspective. I'm sure that they would prefer to continue to balance bill patients. From a health plan and insurer perspective, also the law does address who this is applicable to. So obviously to the insured and self-insured plans, ERISA, traditional indemnity plans, the exchange plans, student health coverage, it is applicable to all of those. It is not applicable to Medicare managed care, Medicaid managed care, even fee-for-service Medicare, Medicaid, because they already have prohibitions related to balance billing a patient. It also does not apply to short-term limited duration plans. And one thing that I've included in the slide is that it does not apply to health sharing ministries. I think you've all heard a lot of ads. And as you were in the hospitals, they had patients present with coverage through a health sharing ministry. Those are not licensed insurance products. And therefore the law is not applicable to those products. You would be allowed to balance bill a patient in those cases. In terms of notice, and I'm jumping into notice before I actually get into some of the requirements about when you can balance bill and when you can't, because this is really the first step in what you have to do. And there is, and when we talk about surprise billing, I'm going to discuss a notice and I'm going to discuss a consent. So let's start with the notice. The notice is information that was provided by CMS. They actually gave you a model notice that you could use. And I will provide you, show you a copy of the beginning of that momentarily, but you are required to take this notice and post it on your website. And you are also required to display it somewhere prominently within your facility. Most hospitals that I'm aware of are posting this right next to wherever they have posted their HIPAA notice of privacy practices. And this could be multiple locations within your facility, but they are taking this notice, they are posting it. CMS and the parties, the multi-agencies that are involved in this law, they have all said, post it prominently. We are assuming most providers will post it wherever they have posted their privacy notice. But we also recognize that a lot of providers have these posted in various places throughout their organization, because various locations for intake and registering patients. So you do need to really think about where you are posting these signs and where they're necessary. But I do think that if they're posted near the area where your HIPAA notice is, you probably will be okay. You are also going to have to post the notice on your website and include a link from the homepage to the surprise billing patient notice. And last but not least, you're going to have to give the patient notice to all of your insured patients other than Medicare and Medicaid to whom services are provided. I wanna be kind of picky on this. It has to be provided no later than the time that you are asking for payment. So if you're asking patient to pay for services when they're receiving an outpatient service and ask them for their out-of-pocket liability, you are going to have to provide this notice to them at that time. If on the other hand, the patient presents in the ED, the ED stabilization period is over, you are going to wind up continuing to treat the patient and you are perhaps you're a facility that is going to talk to the patient at that time about the fact that their insurance is that they are out of network by receiving care at your facility. Stabilization has occurred. If you are talking to them about money, then you're going to need to give them this notice about their rights under No Surprises Act. But recognize that it's not an issue of someone having to run into the room in the emergency department to provide the notice once the patient is stable, unless you are also talking to the patient about paying for the services rendered. The provider, meaning the physician practitioner, can enter into a written agreement with the facility to rely on your notice so that you're not giving the patient a notice as the facility and then a physician coming in and providing notice as well. You can go into and have an agreement with your providers that your notice would suffice. Otherwise, they are going to have to deliver the notices themselves. This was something that really, hopefully, prior to the end of last year, you were working on these written agreements with your practitioners, providing services at your facility, but very doubtful that you have gotten everyone, a written agreement with everyone as of yet. This is what the notice looks like. This is the model notice. Couple of things I want to call your attention to. First of all, this is really a two-page form, although it's said to be one page, but it typically is going to be a front and back that you are going to give the patient. You can see in the first column towards the end, there is insert plain language summary of any applicable state balance billing laws. You're going to need to take the information that has been published by GHA or shared earlier by Donna, and put that into this form because you do need to apprise them of their rights under state law. And then there's also on the other side, request for additional information related to state balance billing, about who to contact for more information and additional website information. There is a phone number that I have put on the bottom of this. You may contact, which is the phone number that was published that patients can use as well as the consumer website related to no surprises that is maintained by CMS. Those can be used to fill this information in on the form that you provide, but you do have to make this available. Kathy? Yes. I'm sorry to interrupt. This is Donna. I just wanted to note one thing about the model notice, and that is that GHA has provided a sample notice that has the Georgia information. I think everybody on this call would have received that, but if not, you can certainly email me and I'd be glad to share it. We also got a question and it is, how do we handle pre-registration via phone call? We register and ask for the out-of-pocket at that time. We cannot hand them the actual paper over the phone. You're going to have to ask them how they would like it delivered to them. You can email it, but you do need to make it available to them when you are talking money. You can't just read it to them. You might want to refer them to your website, but you would need to make this available to your patient. And you do have to deliver it in the manner in which they would like it delivered. Thank you. And I would just like to say kudos to GHA for getting this done and for putting that information out on your website. I guess I should also go ahead talking about the notice and say this does need to be available in the 15 most common languages within your market. So recognize that just like your HIPAA notice, this is something that does require translation. Going on and let's talk about actually providing this notice. There we go. And going to start with in the case of emergency services. And when we're dealing with emergency services, the law is applicable whether or not the facility is in network or out of network. So assume that the facility is in network, the practitioners are out of network, the law will apply to them. If you are an out of network facility, the practitioner is out of network, it still applies in the case of an emergency service. Case of an emergency, the law is always applicable. And this is a scenario I'm going to share with you in a minute in terms of something that has recently happened. When we start talking emergency services, I think this is where we did have a couple of provisions that were included in the law that were positive because of some things that we had been dealing with historically. The first relates back to a patient presenting to your emergency room. Emergency services patient is treated in the emergency room and needs to be admitted for additional services urgently. And you might admit that patient. And then you wound up billing their insurance and you would get a denial saying that the patient could have been transferred to an in-network facility for the post-emergency department services. And therefore, you got paid ED but not for the additional care that you provided. Under this law, it is the treating physician who could be the emergency room doctor or the physician who is providing inpatient or even observation care to the patient who determines when the case is no longer an emergency. It does include post-stabilization services in that it must be included in this discussion of coverage for out-of-network services. Post-stabilization is included and until actually in the way they have defined the covered period is the treating physician determines that the patient can be moved to another facility using non-medical transport. So in the scenario that I gave you where the insurance said the patient could have been transported by ambulance to an in-network facility. Under that scenario, under the new law, that is not considered the stabilization period over. And therefore, it would have to be covered and the patient would be able to be treated in your facility and the payer would have to pay. They also are reinforcing the use of prudent layperson. And they are saying that a payer cannot limit coverage for emergency room services based on diagnostic information that is on the bill. We did have some payers earlier last year who were going to begin to deny services using artificial intelligence based upon the final diagnosis. This cannot be done. We've got to be looking at why the patient presented for services and it really requires a record review as opposed to using AI to just arbitrarily deny. Now, my horror story in terms of, all right, we've been doing this for almost two months, not quite. I have heard of a provider with a very large payer both across the country. The facility is out of network. It was an emergency service. Patient was admitted from the emergency room to observation. Hospitalist saw the patient in observation and submitted a bill to the payer prior to the hospital submitting a bill. Which often happens. The payer has no information on the hospitalist claim to indicate that this patient came in through the emergency department. Think what a 1500 claim looks like. There's nothing that says that it was an emergency on the physician claim who saw the patient in observation. The payer came back to the hospitalist and said you may balance bill the patient. Well, no, they can't because this was an emergency service. So there is going to have to be some modifications either even in terms of the information that goes on the physician claim. Because I can picture in that scenario if that hospital had not done really good education with their docs and the doctor came in and said, I thought you told me I couldn't do this. I think it could be a real problem because if the physician had gone ahead and billed the patient, once the hospital submitted their claim, there would be changes to the information and essentially the insurer would have had to re-notify the physician. So going to be interesting, and this is something that I am going to raise with the National Uniform Billing and the National Uniform Claims Committees because I think our claims are not communicating all that we need to communicate in these scenarios. And I'd love to know when we go through this if any of y'all are starting to see that as well. So that was emergency services. Let's move to non-emergency services. And in the case of non-emergency services provided at an in-network facility, okay, I'm in network as a facility. The physician is out of network. The law is applicable and prohibits balance billing without consent. Again, if it is an out-of-network facility, it doesn't matter. The law isn't applicable. But if it is an in-network facility, even with a non-emergency service, then we're going to be dealing with applicability of the law to the physicians and other practitioners providing care. Now, a physician can get consent to balance bill the patient. Basically, you would be saying, if you really want me to do this service for you, remember this is a non-emergent service, then if you will sign this consent to be balance billed, then we will move forward. That's really probably going to happen very rarely. It's going to be in the case of a surgeon, I think predominantly, maybe some consulting physicians. But in those scenarios where I want Dr. Smith to do my surgery, and I am going to an in-network facility, he is out of network with my insurance, but I want him to do my surgery because he is the best. I can agree to be balance billed in advance. However, there are a number of practitioner types that are not allowed to balance bill even with consent, and they are pretty much listed on this slide. Your ED physicians, anesthesiologists, radiologists, pathologists, neonatologists, assistant surgeons, hospitalists, intensivists, they are never going to be able to balance bill. In addition, certain ancillary services such as radiology and lab cannot be balance billed because this is not something the patient was going to be aware of in advance. Those services that are related to an unforeseen or urgent medical need, such as a change in surgery, a midstream, not what was approved or authorized, now it's something different. You cannot get a consent to balance bill for that under the law. And if it is an out-of-network, if there are no in-network providers available to furnish the service, then the services that are provided by the out-of-network provider can also not be balanced billed. You cannot get consent to do that. So if there is no one in-network to provide it, you're not going to be able to get consent to bill out-of-network. So very few physicians or practitioners are really going to be able to balance bill a patient to even get consent. One thing that I would raise about this is for those of you who are actually from a hospital perspective, employing these is, as I say, the anesthesiologist, the pathologist, radiologist, the hospitalist, et cetera. I think this is going to become an issue from a contracting perspective because many of these individuals were not historically in-network. They did balance bill. Now that they cannot balance bill, are they going to want to be renegotiating with the facility in terms of perhaps making them whole? So something that I think we need to be aware of. There is a standard consent notice that has been published. I've given you the location of this. The timing of this consent is very important because I'm going to talk consent in a little bit related, actually not consent, but notice under the good faith estimates and recognize that under both the consent to balance bill and the notice of a patient's expected out-of-pocket liability, if they are self-pay, there is timing involved. So if the service is scheduled at least 72 hours in advance, you're going to have to provide that notice 72 hours in advance. So again, you're providing it to them right away. And that notice includes what they are expected to owe, that kind of thing. If it is less than 72 hours in advance, and this is one I'm still trying to figure out, it's less than 72 hours in advance. You've got to provide the notice on the day of the appointment, but not less than three hours prior to the service. So does that mean you are going to have to have a patient present to your facility for the physician who has gotten the signed consent or is going to get a signed consent to meet with the patient three hours prior to the service that they're having done? And what happens to the patient during that three hour period after signing the consent and before they can have the service? Are they sitting in a lobby? I don't know how this works and I don't know how we operationalize it. But if it is that service that is scheduled less than 72 hours in advance, they must have the notice at least on the day of appointment but at least three hours prior to the service being rendered. So concerned about how we actually operationalize this. The signed consent must be provided to the health plan and it must be communicated on the claim that you have a signed consent. However, we don't have the ability to do this yet in terms of communicating it on a claim. And so this is one of those things that sometime between now and July, we are expecting additional rules on. So stay tuned, we're going to have more rules probably issued as interim final rules that further addresses what we are going to have to do. Now, in terms of what, I have gotten the patient to sign a consent that they agree to, I'm sorry. This is in the case if I don't have a consent, the qualifying payment amount comes in. And I am not going to be able to charge a patient any more than their in-network cost sharing amount. So the patient has gone out of network, that hospitalist for example, is not going to be able to charge more than in-network cost sharing, not going to be able to balance bill the patient for additional amounts. And they're going to determine that in-network cost sharing based upon what is called a qualifying payment amount of QPA. And the QPA is basically calculated. Let me start with how it's calculated. It is the health plan, the specific health plans, 2019 median in-network rate paid for the same or similar service in the same geographic area. We've had a lot of discussion in terms of our plans, taking people out of network so that they can lower the QPA. Well, that's not why they're doing it, but we might want to talk later about why they are, but recognize that we are starting with a 2019 rate and each year that 2019 rate is going to be indexed and increase slightly. I actually have a slide and if I can find it, I will share it with you. But the increase in the QPA is very minimal from 2019 to current. There was information published in December by, I believe it was the Department of Labor that gave that increase. And so recognize small jump in the rate from what was in place in 2019 to what it would be in 2022. And each year it's going to be indexed. So under the current law, we are not going to actually recalculate the median in-network rate. We are going to keep a slight boost or an adjustment to that 2019 rate. If a provider would like to know what the QPA is, that is going to have to be provided by the payer to the plan. When you present your claim out of network claim to the plan they will be coming back to you with the QPA and what is called an advanced explanation of benefits, an AEOB. That AEOB essentially is going to show what the plan would allow, which would be their QPA and what the patient liability is. And this is going to come prior to the rendering of services so that you can tell the patient their liability. This again has been postponed. We should have more rules related to this by July. Now, going to talk for a minute about the current dispute resolution process. And then I'm going to turn it over to Donna to talk about dispute resolution on the federal level. You have submitted a claim and you are not happy with the amount paid. Prior to, I think about two days ago, the amount that you were going to be paid as an out-of-network provider was the qualifying payment amount. This all of a sudden, I guess a little bit of history, when the law was written, there was a lot of discussion about what should be paid to out-of-network providers. And Congress would not decide. They essentially said, no, we're not making that decision. All of a sudden, we got a rule that said that the interim payment amount would be the qualifying payment amount. And as a reminder, that was the 2019 median in-network rate indexed up to 2022. There's been a considerable litigation related to this. There was litigation in Texas. There was litigation by the American Medical Association and the AHA, I believe the AAMC. So we have had litigation about should the initial payment be the QPA? So earlier this week in Texas, the court did decide that the amount, that the QPA was not appropriate. Congress has actually easily decided Congress has actually even, there have been, I think, almost 200 signatures on a letter saying, no, we didn't say it would be the QPA. So I think ultimately we're gonna see this struck down and a change in the rule. But until we get beyond the Texas court making that decision, initial payment will probably be the QPA other than Texas. But your initial payment comes in. You're not happy that initial payment. You have 30 days as a provider to begin a discussion with the payer or to tell them that you're not satisfied and to begin an open negotiation period. That open negotiation period is going to last 30 days. Following that open negotiation period, you only have four business days to initiate a independent dispute resolution process. Think baseball style arbitration, where you are going to say, this is how much you think you should be paid. And the payer is going to say, no, this is how much I think is the appropriate payment. The appropriate payment, they could come up with just about anything. You can come up with just about anything. However, it can never go back to what your charges are or you can't really be saying it should be charges. And the payer can't say it should be the Medicare or the Medicaid rate. So there is four days to institute or initiate the independent dispute resolution process. You're going to pay a fee, a $50 administrative fee for that process. And then you're going to be providing additional information to the dispute resolution entity. Information that I will share on the next slide. The IDR essentially has 30 days to make a decision. As to whether the amount requested by the payer or requested by the provider is the amount that they should get or the amount proposed by the payer. They can't come up with anything else. It has to be one of the two amounts that was presented to them. And then, so they have 30 days to decide that. And then another 30 days for payment to be made. And the payment has to be made to the provider. It cannot be made to the patient and then the provider have to go and collect. That's been a problem in the past. Payment has to be made from the payer to the provider. When we look at the process for the dispute resolution at the federal level. We were initially told that we would work from the presumption that the qualifying payment amount is the appropriate payment rate. We will see if that is what is maintained by the courts because it is not what was maintained in Texas. But then ultimately, and as a part of your dispute resolution, you're going to be arguing that the amount that you were paid was not appropriate and you are going to then provide information as to why that dollar amount wasn't appropriate. So think about arguing information based upon training, experience, quality, outcomes. What is the market share? And this could be argued both on the part of the provider and on the part of the plan. What about the patient acuity or the complexity of that particular patient compared to the typical patient? Was there, did both parties actually come together and work together to try and come up with an agreement during this? And also there would be information if you were ever contracted with this payer, what were your contracted rates over the last four years? And I think that is a really interesting thing to present because we do know particularly some physicians who have suddenly found that they are out of network. They have been contracted historically. They were offered significant reductions in their rates and absent taking those reductions in the rates, they would be considered out of network. By providing the information over four years of historical contracted rates, I think it can make the arbiter question, well, why are you saying this low rate is good when for the last three, four years you've paid them significantly more? And as I mentioned, you cannot base this upon Medicare, Medicaid rates or customary charges. With that, I'm gonna give it to Donna for a minute on dispute resolution and then from the Georgia perspective, and then we're going to take at least one question because I see it in the Q&A, but I would ask Donna if as you're going over the Georgia dispute resolution side, if there are other questions that need to be included, please folks, raise them. Donna. Thanks, Kathy. So just, there are a lot of similarities between the state and the federal dispute resolution process, but there are a lot of differences too. In terms of the timeframes, it's again, 30 days for you to dispute a payment. So once you receive a payment from the payer, you have 30 days to request dispute resolution. Now it's a little different. This is also the period during which you can negotiate with the insurer. So that's a little different from the federal provisions, but again, 30 days is the key there. Within that 30 days, the insurer has to submit all of the necessary information and as I said, can negotiate during that time. After the initiation date of dispute resolution, the parties have to reach agreement on a resolution organization to use. And the state does have a process to approve resolution organizations. We don't have a complete list of those, but that is something that the department's maintaining. Like the federal provisions, each party submits its final payment offer. Again, it's baseball style arbitration. So each party submits the order with their justification. And again, it really is the key point that Kathy made in terms of justification for the rate you request. And that has to be done within 10 days of the selection of the arbiter. And then the arbiter picks one of the two within 30 days. They can ask for more information if they feel they don't have enough one time. And I believe that's limited to 20 days. I should have verified, I'm sorry, to 20 pages. And then once the arbiter has made a decision, the party that wasn't selected has to pay the expenses and fees. And the monies have to be, the money due has to be paid within 15 days of the decision. The big difference here is that the state has not defined the fees, and unlike the federal process. And then within three days after the monies are paid, it has to be distributed to the applicable party. Let me go ahead, Kathy, and read the question. All right, we have in the Q&A, is there a standard method to submit requests for open negotiations, or can each plan dictate how the requests could be submitted? In other words, require the use of the plans portal to receive requests? Actually, if you go to cms.gov, and it's the IDR process that you would search for, there is a portal to submit a complaint. And that's the process that you would be following. There is quite a bit of information on that site. And I urge you to take a look at it, because it addresses not only your process for the actual portal for submitting a complaint, but it also addresses, it provides information on the parties who are becoming the IDRs. And it goes through who they need to be and those that have actually been approved. So some of them might be names that are familiar to you. So I urge you to take a look at that. But it is not plan specific for the IDR process. You are actually going to a CMS portal. Before we go into the discussion of good faith estimates, are there any other questions? Type quickly. Okay, we will catch you on the other side. If you do have additional questions related to no surprises, but we'll do good faith estimates now. And then we'll have a little bit more time for questions. On the good faith estimate. This is where I said, we're now all of a sudden, we're going to be getting into something that the first rule applied only to services furnished in a facility. Now we're getting into services that could be furnished in a facility or in a physician's office or a clinic or all kinds of other places, all right? So first of all, I got to do a quick definition of what I'm calling a convening provider. A convening provider is going to be the entity that is responsible for scheduling a primary service for a patient. Now, use it from the scenario of, I'm going to have a, oh, let's just pick something horrible. I'm going to have a colonoscopy. And is it the physician who is scheduling the service or is it the outpatient center where it's being done? Who is scheduling the service? Because it is that convening provider that as of right now must begin to share information related to the cost of the service for self-pay patients. As of right now, 2022, it is the convening provider who must provide information related to the cost of the patient's liability. Beginning in 2023, that convening provider is going to have to also provide to the patient expected payment information related to any co-providers. So I'm going to give the scenario of it is the, no, it's the ambulatory surgical center who schedules the colonoscopy. Right now they're giving their estimate. January, 2023, they're going to be giving an estimate not only for what is expected to be paid to them, but also what would be expected from the physician doing the service, the anesthesiologist, any co-providers. So much more involved. So think about it from a hospital perspective, those services that you are providing right now to a self-pay patient, you are perhaps scheduling. Do you have the ability to capture the expected charges from co-providers? Because this is something you're going to need to be able to do next year. The requirement is that you provide a good faith estimate of total expected charges, first of all, to a self-pay patient who is just shopping and wants an estimate of what it would be. I have a feeling that you might be seeing more and more shoppers as this hits the news and people are aware that this is a provision. They might not really be shopping. They might just be wanting to see if you're compliant. But A, you must make the good faith estimate available to those who are comparison shopping. And secondly, you're going to have to make that good faith estimate available to any self-pay patient who schedules a service at least three business days in advance. And we'll talk about the timing of providing that notice in a minute. But if the service is scheduled at least three business days in advance, it's got to be, you've got to provide them that good faith estimate. And seeing this question a lot, there is a requirement for you to give them a good faith estimate. It's not a question of they don't want it. It's a requirement that you must provide. The requirement right now is that you are going to be, if you are the scheduling or convening provider, you are going to be providing a list or a price for those services that you provide, as well as any professional services for which you bill. Beginning in 2023, as I mentioned, you would also have to be including that co-provider information, whether you bill for them or not. If you request information from that co-provider, they have one day to give it to you. This is a very short turnaround because remember you've got to provide that information to the patient when they've scheduled the service. Now we're adding, tacking onto this that the co-provider has a time period to make information available to you. So we'll kind of look at this as we go through. When I talk self-pay, and I've done a lot of No Surprises Act presentations with Marty Ross from our Kansas City office, and Marty has been real good in terms of, it's not just the uninsured patient. We have to use the term self-pay because this could be a patient who is uninsured, has no insurance coverage, but it could also be the patient who has insurance but doesn't intend to submit the claim to their insurance. It would also be the patient who has insurance but the particular service that is being provided is not covered. And last but not least, the patient who has coverage but has insurance, but they're going out of network and there is no coverage for out of network services. If it's the case that they've gone out of network and they are going to face a higher out-of-pocket cost, they still have insurance. So you don't have to give them a good faith estimate. But if there is no coverage for an out-of-network service, you do have to provide them that good faith estimate as well. Now, I'm gonna share some information including some screenshots of the good faith estimate because there's some things on here that worry me. One thing that you're going to have to do is remember earlier we talked about putting that notice about the No Surprises Act protections for patients up on your wall? Well, right next to it, you're also gonna be posting a notice related to good faith estimates and the patient's rights to receive a good faith estimate. This is going to need to be on your website. It's also gonna be at physical locations. As I said on this slide, probably you're gonna put it next to the Notice of Privacy Practices and the Surprise Billing Notice. So one more thing for you to make available. The model notice, I've given you the location of where that notice itself is. We'll talk after in a few minutes about that $400 issue related to the patient's right to dispute. So we'll talk about in a minute. You can also see down there that there is a little bit of a, this notice is to the patient. It says, be sure to save a copy or picture of your good faith estimate. We'll talk about that. But a couple of things I wanted to share. First of all, and I'm gonna go back a slide, two slides, whoops, here we go. You're gonna give this good faith estimate to the patient who's comparison shopping or to the patient who is receiving services that are scheduled at least three days in advance. Your good faith estimate, in addition to giving it to the patient, you're going to have to maintain a copy of that good faith estimate. Now, most providers are taking, and very easily for the patient who is scheduled, they are putting that good faith estimate as a part of the patient's EHR. That is essentially the requirement because you do have to maintain it with the patient record. So you're going to some way or other get that good faith estimate into their record. But I now have the patient who is comparison shopping. And how am I going to maintain that good faith estimate for someone who is not a patient? They are just calling up. They are asking for a good faith estimate. Where am I maintaining filing this information? And it really is something that you need to be thinking about because you do need to maintain that good faith estimate. So I went through this. The patient is told to make sure they keep a copy of it. You also are required to maintain. A lot of presentations, this is what you see on the good faith estimate. I want to be clear that this is actually a four-page document that you are giving the patient. And this is patient-specific. It is service-specific. You can see that on the good faith estimate, it's asking you for the patient name. It's asking for their date of birth, their patient identification number. You don't have that if they aren't yet a patient, unless you have some type of a fudged numbering system. How does the patient want to be contacted? By mail or, excuse me, or by email? What is the primary service that they're having? What is the date of this good faith estimate? And for the convening provider, what is the estimated total cost? And for any other providers that are involved that I'm providing this for, what is involved? I want to show you another page of this good faith estimate. And this is the page that bothers me because we don't have good instructions, that's all I can say. And CMS keeps doing webinars. They did one earlier this week. On No Surprises Act, they have yet to do anything on good faith estimates. And there's a lot of clarification, I think, that is needed. And I have seen lots of different programs on this. One in particular makes me very nervous. But you can see, this is the provider facility estimate. This is the first provider facility. Who are you, your address? Who is the person who is doing this? Your national provider identifier and your taxpayer identification number, okay? Details of services and items. Okay, now remember here, I had an estimated total cost. Now I'm getting into details of services and items. What is meant by details? I can see as an example under diagnosis code, it asks for an ICD code, for a service code. This is where it throws me. Service code number. Does this refer to maybe a charge master code, a revenue code? Then we get into quantity and expected cost. And this is details. Are we getting into something that looks like a UB? I actually did see a presentation where someone presented that, and that their scenario, don't know where they got this information, but their scenario was essentially a UB. The detailed charges associated with the services provided and how they would total up. That is going to be very, very hard to do prior to services being rendered to say, this is what I think the detail of your bill is going to be. Do I run this off of my price estimator and the fact that the service, let's say a hip replacement is being done by Dr. Smith and his bills typically look like this for a patient of this age. And then what about the difference in the implants that he might be using, et cetera? So very concerned how we are doing this right now and what we are ultimately going to be expected to do related to this particular section of the good faith estimate. Additional information related to the GFE. Obviously we've got to include any diagnosis and service codes, the charges associated with each. You can provide a range of service if there is a specific level or type unknown. Think about from a physician office perspective that the patient is coming in for an initial patient visit, well patient visits. This could be a level one, it could be a level three, it could be a level four. So essentially you could provide that range of services and making it clear that it depends upon the complexity of the case. It also has to be inclusive of any applicable discounts. So there's a question that we get quite often, the charges, patient qualifies for charity and we're not gonna charge them anything. Do I still have to give them a good faith estimate? Yes, the answer is yes. And the information is gonna be that they would owe zero. But you do have to show them this with the expected patient liability to be inclusive of any discounts that you are offering. Let's talk about timing of this good faith estimate. Remember I said you have to, in January of 2023, you're also gonna be providing information related to any co-providers that are involved in the care. So if it is requested prior to scheduling, you have three days following the request to give them the good faith estimate. This is for that patient who is shopping. If the service is actually scheduled and it is scheduled at least 10 days, but less than four days in advance, you're going to be providing the good faith estimate three days following scheduling. Three business days in advance, it's one day following scheduling. And if the service is provided in, it's gonna be provided in two days, you do not have to give them a good faith estimate. It's only when services are scheduled three days in advance. If we're dealing with a recurring service, such as a patient who's coming in multiple times for physical therapy or dialysis or something like that, you may give them a good faith estimate that carries over for a period of time, but that period of time can not exceed a year that you're giving them that GFE for. Finally, there is a dispute resolution process related to this. And if you go to that same website on the CMS website related to the IDR process, there is a portal for the consumer. And here we go. If the amount that you put on the good faith estimate, remember you've already got this on that notice you posted on your wall and on your website and gave to the patient. If the amount that you are actually billing is $400 or more than the amount that was on the GFE, the patient has 120 days to initiate dispute resolution. They would pay a $25 administrative fee to begin the dispute resolution. Rather than an independent dispute resolution entity, we would be dealing with a selected dispute resolution entity that they would file the complaint, patient files the complaint, the SDR is gonna notify the provider, you've got 10 days to respond with why your charges were higher than your estimate by more than $400, 400 or more. And then based upon that information, the select dispute resolution entity has 30 days to decide whether or not the amount is appropriate. Now, here's where we get into. So then I get paid my charges, huh? No. If there is no credible evidence of why the charges are greater, then you're gonna be held to the good faith estimate and that's all the patient is going to owe. If there is credible evidence, then you are going to be held to the lesser of your bill charges or the median payment amount paid by a plan or issuer for the same or similar service by the same or similar provider in the geographic area reflected in an independent database. So there is no assurance that you're ever going to get that GFE. You might get the GFE, but you also might get that median plan payment amount that would be maintained in an independent database. So I think it is our goal to be very careful about GFEs and about getting them as accurate as possible. I think one of the things we need to consider, particularly as we look to the special rules for recurring services is what happens if mid-year I change my GFE charge master rates. Depending on what the recurring services are for a particular patient, let's say patient is coming in for chemo and it is a self-pay patient. And many times in pharmacy, you adjust your pharmacy charges practically weekly. If you suddenly are dealing with a claim going to a patient that is $400 or more than the GFE, then you could be dealing with the patient going to dispute resolution. So I'm not sure that I would go a year out in giving a GFE. I think I would be very, very careful. And in the case of the patient who is shopping, who then comes back to you to actually schedule, I would want to give them a new GFE at that point as well. Just because you don't know what could have happened to charges within your facility just for one or two items within that. So it's February 25th. Yes. Before we move on to the checklist, we do have a couple of questions specific to Good Faith Estimates. Would you like to go ahead and hear those? Sure. Okay, the first is how does the Surprise Billing Act and the Good Faith Estimates apply to the Outpatient Radiation Oncology Department? We currently give patients their estimates prior to the radiation delivery. However, we're being asked to provide this information after consult. We don't know what's going to be done until after the radiation planning has been done. I'm not sure, it says charges are accruing at that point. So how does this need to be handled? The only thing I can suggest is that you start off with providing a Good Faith Estimate on the initial services that are being provided with the statement that once we have your treatment plan in place, we will be providing you more information. It is very difficult for any patient, any provider to figure out how they're going to do this. I know that we've got Carrie on the call too, and I would ask for her advice, but I think all you can do is provide what you know at that point in time, which initially is going to be the evaluation of the patient. And then you're going to wind up giving them another GFE for the course of treatment. Does that help? Thank you. I think this is Carrie. I think that that's right in terms of potentially having to do a second GFE. And then once you are able to do that second GFE, then there is that provision that allows you to provide one estimate for recurring services, as long as you are taken back to make sure it's updated. Right, but if you're doing that, particularly again, radiation oncology, I would be very, very careful because you need the cost of drugs change, the actual drugs might change. So be careful on that. I wouldn't go too far out in providing a GFE. Kathy, the next question is just to clarify or to confirm that it has not been clarified whether the service code refers to the CPT code or the revenue code. It has not been clarified. I have seen things both ways. It just, I get nervous when I see quantity on there and I get nervous when I see people who I think know what they're talking about provide something that looks like a UB. Okay, thank you. I would urge folks at some point there will be instructions coming from CMS and you might even want to start asking those questions and putting them, submitting them to CMS and asking for them to provide some insight because this one really worries me. What is it supposed to look like? Okay, we've got several more questions, Kathy. So I'll keep going. No problem, but let me just say it is the word detailed services that worries me. Detail. Go ahead. Okay, do you recommend standardized good faith estimates for all services provided with patient specific discussions if you expect their service to be above and beyond your usual cost? I don't know if that is referring to, should I just go have one printed up that says here is a clinic visit and here it is? I don't know that I would do that. I think I would be doing this very customized to the patient and their particular condition. Remember, it's gotta have diagnostic information on it. It's got to have service code information on it. I'm not sure that you can just arbitrarily prepare these in advance. And also I'm gonna be very blunt. Dr. Smith's patients might have, okay, let's do it this way. Dr. Smith and Dr. Brown are both orthopedic surgeons who do hip replacements. Patient is coming in for a hip replacement. Dr. Smith does them and he uses a particular implant and the patient tends to go home the same day. That was Dr. Smith. Dr. Brown's patients come in the night before and he uses a totally different implant. And his patients tend to be done in the afternoon and actually stay another night. You're gonna really have to narrow this down to who is involved in the care of the patient because different physicians treat differently. One thing that we've talked about in our GHA round tables too is the importance more than ever of educating your physicians on their documentation because when there are unexpected services that are provided that can affect your estimates, it's important for them to document that it was a good decision to do it. To document that it was unexpected or to make sure it's very clear in the medical record. Right, because remember when you, if the patient does dispute, it is the fact that it was not as expected that you're gonna be providing for why the bill was higher. Good, thanks. Next question, are there any penalties for failure to provide the good faith estimate in accordance with the required timeframe? My understanding is, and Carrie or Donna, I believe it is a $10,000 for instance penalty. I am not certain of the answer there. That is my understanding. Okay, good. I'm just gonna be real blunt and say, we all know that there are people calling around for GFEs just so that you can, just hoping that you will say we don't do that. I will say, Patti, I don't, that amount sounds right to me, but I don't have it sitting here in front of me. I will say just generally about enforcement that there are still a lot of unknowns in terms of how enforcement is gonna work. Georgia and a number of other states have received letters from CMS detailing what the state believes they have the authority to enforce as it relates to fully insured plans governed at the state level and what they don't have the authority to enforce. But then at least in Georgia, the insurance commissioner's office has agreed to enter into a collaborative agreement with CMS to enforce even the provisions for fully insured plans that the state doesn't think it has the authority to enforce. The idea being that if the plans know that they may ultimately be subject to federal enforcement, that they will voluntarily comply once the state has pointed out to them that they're doing something wrong. And so we, for those of you that have been around insurance for a while in Georgia, there's not a lot of enforcement going on right now or historically in Georgia related to these specific types of issues. And as far as we know, the Department of Insurance is not receiving any additional resources in order to help with those enforcement efforts. And so I, for one, am paying pretty close attention to how all of that starts to play out here in Georgia. Thanks, Carrie. So we're down to three minutes and we have six questions outstanding here. Donna, everybody can read this slide. This slide is, have you done what you're supposed to do? So let's go with questions. Okay, how do we handle sliding fee scale patients in a rural clinic that are self-pay? Patients are not walking their schedule. You're still going to have to provide a good faith estimate. As long as they are scheduled three days out, you're going to have to give them a good faith estimate that is inclusive of their discount. Good, thanks. Let's see, we had a clarification on a couple of past questions. Let's see. So the one about not knowing the charges before the service is provided, I think has been answered in terms of your documentation necessary from the physicians. Yes. And yes, the good faith estimate is for self-pay patients, but keep in mind what Kathy has said in that that would include somebody that doesn't plan to file with insurance or somebody that, or coverage that does not, sorry, I didn't say that right, or an insured that does not cover the service. Let's see. Is the penalty only assessed if we hold the patient responsible for the higher amount? Well, I guess once they get the bill that shows that it is higher, they would have the right to seek resolution. If what you're saying is before I send the bill, I adjust it, then you'd be okay because they wouldn't have gotten a bill for the higher amount. Now, again, they might complain to you and say, you told me it was going to be $1,000, it's $1,400. And you can say, okay, well, we will back out. Then again, they have nothing to complain about. You did not expect them to pay that $400. Okay. And this'll be the last one, but for patients with a direct admit from the MD office, not through the ED, has anyone come up with a way to estimate the inpatient stay when we don't know the medical situation well enough to categorize it? A direct admit from the physician's office is not a three-day prior scheduled stay. Great, thank you. Okay, remember we're talking schedule. This becomes a real big issue if I go to the physician's office, because remember, this is Apple in the doc's office, okay? I go to the physician's office and he does labs and sends them to the lab, okay? Well, that lab service is not scheduled. Or if he tells you, I want you to go over to the lab and have this, you know, here's a script to have something done, and you just walk in and have it done at the lab, that is not scheduled three days out. Great, thank you. There's a question about the presentation, and I just want to point out that if you'll look in the chat, Lindsey has posted a link there to the presentation. And you have our emails at the beginning of the slide deck. If you have any questions, please don't hesitate to reach out. I just want to say to the providers on the call, thank you for all you do. I think it is extremely hard with everything that's going on and has been going on the last two years for you suddenly to be faced with having to become compliant with this as well. So anything we can do to help, please don't hesitate to ask. Thank you, Kathy. Lindsey, do you- So, yep, absolutely. Thank you, Donna. As Donna mentioned, I did just, again, post a link to the slides there in the chat. And as a quick reminder, you all should receive an email tomorrow morning. Now I know that will be on the weekend, but that will include both the link to the full recording of today's session and again, a link to the slides. And just a quick reminder, if for some reason that email does go to your spam folder, you can always go back and use that same Zoom link that you use to join today's live session to also access the recording. And the recording should be available through that same link within an hour of us concluding today. And again, as Kathy and Donna mentioned, if you have any follow-up questions, please don't hesitate to email us and let us know. And if we can help facilitate that, you can always email us at education at gha.org. And we'll be happy to get the question over to either Kathy or Donna. We'll be happy to help in any way that we can. Thank you all so much for participating with us today. And thank you for your questions. And thank you so much to our presenters, Kathy, Donna, and Carrie, for your great information that you presented today. And with that, we can go ahead and close out today, unless Kathy or Donna, you have anything left to add? Just thank you guys. Thank you. Okay, great. Thank you so much. Hope you all have a wonderful afternoon and a wonderful weekend. Thank you. Bye.

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