I had an appointment scheduled with an endo that I’m 99.999% sure my health plan isn’t going to pay for so I asked for a good faith estimate (GFE). The law requiring GFEs took effect in 2022 so they’re still kinda new in health care and I didn’t find much info for patients. The doc’s office gave me the runaround so I’m hoping posting this will make it easier for someone else.
To get a Good Faith Estimate (GFE):
- Ask for one when you schedule an appointment
- The provider is required to give a GFE only if either
- An individual who does not have benefits for an item or service under a health plan or
- An individual who has benefits for such item or service under a health plan but who does not seek to have a claim for such item or service submitted to such plan or coverage.
- If you are paying with a health plan you can ask for a GFE BUT
- the provider isn’t required to give you a GFE
- the timeframe rules do not apply
- you can not use the GFE dispute resolution process
When I asked for a GFE the first response I got was “$40-$400”. This is not a GFE. While a GFE can be verbal they have to be specific and if there’s a discrepancy later they have to be in writing so always ask for one in writing, accessible and in a language you understand. All licensed facilities and providers have to give a GFE. In the case of multiple providers, for example a surgery, the one you schedule with has to provide the estimate. The GFE has to be provided in 3 business days if the appointment is in 10 or more business days, within 1 business day if the appointment is in 3-9 days.
In the end with the so called “cash pay discount” the total was $559 for CPT code 99205 Office/Outpatient New High Mdm or 60 Min.
If the charges from each provider and facility is $400 greater than the estimate you can choose to use the Department of Health and Human Services dispute resolution process. Dispute a medical bill | CMS Note that despite the page being a part of the CMS web site the dispute resolution process has nothing to do with Medicare or Medicaid.
The surprisingly easy to read law mandating GFEs is here: eCFR :: 45 CFR 149.610 – Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals.. I also referenced https://www.cms.gov/files/document/gfe-and-ppdr-requirements-slides.pdf