No Surprises Act and FQHCs: Why Compliance Is Important

‍The No Surprises Act protects people from surprise medical bills. These medical bills arise when consumers inadvertently receive care from out-of-network hospitals, physicians, and other healthcare professionals.

The No Surprises Act applies to hospitals, urgent care centers, rural health centers, critical access hospitals, and more. Read on to learn more about the No Surprises Act and whether it applies to federally qualified health centers (FQHCs). We will also cover good faith estimates (GFEs) in the No Surprises Act, penalties for FQHCs that don't comply with the No Surprises Act, and how GFEs can help FQHCs.

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Does a Federally Qualified Health Center (FQHC) Have to Comply with the No Surprises Act?

Yes, FQHCs have to comply with the No Surprises Act.

Under the Social Security Act, an FQHC is a reimbursement designation from the Centers for Medicare and Medicaid Services (CMS) and the Bureau of Primary Health Care. Organizations with the FQHC designation provide comprehensive preventive and primary care, including mental health, oral, and substance abuse services to people of all ages, regardless of their health insurance status or ability to pay.

FQHCs are also called community health centers (CHCs), community/migrant health centers (C/MHCs), and 330 funded clinics.

The Overlap of FQHCs' Patient Demographics with the Patients Who the No Surprises Act Helps

The No Surprises Act was designed to help uninsured and self-pay individuals get fair estimates for their medical bills. Similarly, FQHCs often serve people who don't have health insurance.

Federally Qualified Healthcare Centers Cater to the Underserved and Uninsured

A Kaiser Family Foundation (KFF) study has revealed that FQHCs typically serve medically underserved and uninsured populations and communities.

According to this study, 53% of individuals who receive care from FQHCs have income below the federal poverty level (FPL), and 32% earn between 100% and 199% FPL. FQHC patients also have higher uninsured rates than other low-income populations mostly because they are more likely to fall into the age range — non-elderly working adults — where the risk of being uninsured is the highest. To illustrate, 28% of all low-income people are uninsured, but 36% of FQHC patients are uninsured.

Good Faith Estimates (GFEs) in the No Surprises Act: Required for Non-Insured and Self-Paying Individuals

The No Surprises Act requires healthcare providers to provide comprehensive GFEs of charges for items and services provided to non-insured and self-paying patients. GFEs are documents that outline self-paying or uninsured patients' expected charges for a scheduled or requested item or service.

How To Determine Whether Someone Needs a GFE

To determine whether a patient needs a GFE, ask them whether they are enrolled in one of the following:

1. A group health plan
2. A Federal healthcare program
3. A health benefits plan under a Federal Employees Health Benefits (FEHB) Program
4. A group or individual health insurance coverage offered by a health insurance issuer

If the patient is not enrolled in any of these, they are uninsured. As such, you must give them a GFE.

If the patient is enrolled in one of the above, they are insured. To determine whether they are self-paying, ask them whether they will submit a claim. If they are not submitting a claim, the individual is considered self-paying and must receive a GFE.

What Should a GFE Include?

A GFE issued to an uninsured or self-paying individual must include:

• The patient's name and date of birth
• Description of the main item or service in clear and unambiguous language
• The scheduled date of the main item or service
• A list of the following:

• Services and items reasonably expected to be furnished for the main item or service, such as prescription drugs, encounters, medical tests, facility fees, and medical equipment
• Services and items reasonably expected to be furnished in connection with the main item or service for that care period
• Services and items reasonably expected to be furnished by FQHCs' co-providers and co-facilities

• Expected changes, applicable diagnosis codes, and expected changes associated with each item or service above
• State(s), office, and facility location(s) where the items or services will be furnished
• Tax Identification Number, Name, and National Provider Identifier of each provider and facility in the GFE
• A list of items or services that may require separate scheduling and are expected to happen before or after the primary item or service's care period. The GFE must have a disclaimer directly before this list that includes:

• A notification that information such as diagnosis codes, service codes, facility and provider identifiers, and expected charges do not have to be included for services and items in the list. This data will be provided in other GFEs after scheduling or requesting the listed services and items.
• An explanation that separate GFEs will be given to a self-paying or uninsured individual after requesting or scheduling the listed items or services.
• Instructions for how a self-paying or non-insured individual can get GFEs for these items and services.

• A disclaimer informing the non-insured or self-paying individual that the data in the GFE is only an estimate and that the actual services, charges, and items may differ.
• A disclaimer informing the non-insured or self-paying patient that they may have to request or schedule additional recommended items or services separately and that these additional items or services aren't in the GFE.
• A disclaimer stating that the GFE is not a contract and does not require the non-insured or self-paying individual to get items or services from any of the providers or facilities in the GFE.
• A disclaimer telling the self-paying or non-insured patient about their right to start the patient-provider dispute resolution (PPDR) process if the actual charges are $400 or more than the expected GFE charges.

Required Timelines for GFEs

Once you receive a self-paying or uninsured individual's GFE request or schedule a primary item or service for such an individual, you must contact all co-providers and co-facilities who are reasonably expected to provide items or services in connection with the primary service or item. You should do this no later than one business day after scheduling or receiving the request.

Remember that you must request the co-providers and co-facilities to submit GFE information to you. Your request should prominently display the date by which you must receive the GFE.

Additionally, you must provide a GFE to a self-paying or non-insured individual within the following timeframes:

• When a primary item or service is scheduled at least 10 business days before the furnishment date, you must provide the GFE within three days of the scheduling date
• When a primary item or service is scheduled at least three days before the date of the furnishment date, you must provide the GFE within a business day of the scheduling date
• When a self-paying or non-insured individual requests a GFE, you must provide them within three days of the request date

Required Mediums for GFEs

According to the No Surprises Act, GFEs must be provided in written form either on paper or electronically, depending on the non-insured or self-paying individual's preferences.

Paper GFEs must be postmarked according to the timelines above. Electronically-provided GFEs must allow non-insured or self-paying individuals to save and print them.

If the individual requests a GFE in a form other than paper or electronic, you can orally inform the individual about the data in the GFE. You must also issue the GFE to the self-pay or uninsured individual in written form to meet No Surprises Act requirements.

Penalties for FQHCs Not Complying with the No Surprises Act

As an FQHC, you must comply with the No Surprises Act. If you do not, you may receive a civil monetary penalty of up to $10,000 per violation.

Who Enforces the No Surprises Act?

States are responsible for enforcing the No Surprises Act. The CMS will handle enforcement if the state does not provide adequate enforcement. When determining what penalty to impose, the CMS can consider a range of factors, including:

• The degree of culpability
• The frequency and history of prior violations
• The gravity of the violation
• The impact on affected individuals
• Whether you have made any efforts to correct violations

Note that the CMS may waive penalties if you are:

• Unaware that you are violating the No Surprises Act
• Reimbursing incorrect payments plus interest
• Experiencing economic hardship

How Good Faith Estimates Can Help FQHCs

GFEs aren't just required by the No Surprises Act — they can also help FQHCs. Here's how:

Increase Patient Trust and Satisfaction

First, GFEs can increase patient trust and satisfaction by showing them up-front what they're paying for. Before GFEs, over half of U.S. consumers report receiving unexpectedly large medical bills. This has led many patients to distrust medical providers.

Collect More Revenue

GFEs can also help FQHCs collect more revenue. Patients who know how much something will cost are more likely to proceed with services if they know they can afford them. Meanwhile, patients who don't know how much something costs are less likely to proceed with services — they don't want to be charged with bills they can't pay.

Confidence to Accept Payment Upfront and Have Less Accounts Receivable Days

Finally, if GFEs are accurate enough, patients will have the confidence to accept payment upfront. As a result, you will decrease A/R days, leading to an improved revenue cycle.