Sliding Fee Discounts in Good Faith Estimates: What FQHCs Need to Know

Federally Qualified Health Centers (FQHCs) are recognized and funded by the federal government. These FQHCs must provide care for underserved populations, including uninsured or underinsured people and people with limited financial means.

Many FQHCs provide sliding scale discounts to ensure that these underserved populations have access to care. However, sliding fee discounts can make it difficult for FQHCs to comply with the requirement to provide good faith estimates (GFE). GFEs must be provided to uninsured or self-pay patients as outlined in the No Surprises Act (NSA). These GFEs must include:

• A description of the primary item or service
• A list of items or services sorted by provider that is expected to be provided along with the primary item or service
• Diagnoses codes
• Expected service codes
• Expected charges associated with each item or service

As with all healthcare facilities and providers, FQHCs must provide a GFE for uninsured or self-pay patients or anyone who requests one when scheduling a procedure or item at least three days in advance. Because they are a factor in the ultimate cost, anticipated discounts must be reflected in the GFE. The Department of Health and Human Services (HHS) recognizes that FQHCs will have difficulty meeting these requirements, so they have adjusted the guidelines for providers and facilities that offer sliding fee discounts.

Good Faith Estimate Requirements for Sliding Fee Discounts

The HHS has established conditions for FQHCs to comply with good faith estimate requirements when providing sliding fee discounts. These conditions acknowledge that you may not be able to determine the applicable discount at the time of the GFE. The conditions are different for new patients and established patients.

Requirements for New Patients

As an FQHC, when you provide GFEs to new uninsured or self-pay patients, you must follow the requirements outlined in the NSA, including the itemized list of charges. However, if you don’t have access to information that could affect the sliding fee, such as income or family size, you must at least provide the standard charge without discounts for each service or item. For many FQHCs, this is the price that you charge families with incomes over 200% of the federal poverty level.

If you follow these guidelines, you should also include information about your sliding fee discount and any other financial protection policies you have in place. In practice, this could include a copy of your sliding fee discount schedule and a statement indicating that no one is denied services because they can’t pay, even if you have to reduce fees or waive them completely.

You can also choose to provide information about the expected charges based on income and family size, as indicated in the following chart:

These examples aren’t your only options. HHS allows flexibility when determining the best way to communicate expected charges for each service. However, you still have to comply with all other requirements for providing GFE, including deadlines and delivery methods.

The deadlines for providing GFEs are:

• Within one business day after scheduling if the primary service or item is scheduled at least three days in advance
• Within three business days after scheduling if the primary service or item is scheduled at least 10 days in advance
• Within three business days after a self-pay or uninsured patient requests a GFE

If you follow these procedures, you’ll in compliance with the GFE requirements of the NSA.

Requirements for Existing Patients

The requirements are different for existing patients who already have an established relationship with your FQHC. Because they’ve already provided information about family size and income, you should have more information available to provide an accurate estimate of expected charges for every item or service in the GFE.

However, if a patient tells you their family size or income has changed since their last visit, you have two options for providing a GFE. The first option is to provide a GFE based on the information on file, which is an established patient GFE. Alternatively, if you think it better suits the circumstances, you can follow the procedures for generating a new patient GFE that lists undiscounted rates and information about your sliding fee discounts and financial protection policies.

When you provide a GFE to an established patient, HHS recommends that you include a disclaimer that indicates the GFE was generated based on information you have on file and that the actual charges may be different based on changes in family size or income.

You can also choose to follow the requirements and procedures outlined in the NSA without deviations.

How PPDR Works with Sliding Fees in Good Faith Estimates

The patient provider dispute resolution process (PPDR) is slightly different for FQHCs who provide GFEs based on this guidance. If you give an uninsured or self-pay patient a new patient GFE and their actual charges exceed the undiscounted price by over $400, they can initiate the dispute resolution process.

If you provide a self-pay or uninsured patient with an existing patient GFE, the requirements in the NSA apply. A patient who received an established patient GFE can initiate a billing dispute if the actual charges exceed the expected charges in the GFE by over $400. The patient must initiate the billing dispute within 120 days of receiving the bill with the excess charges.

After the billing dispute is filled, whether for a new patient or an established patient, it will proceed as outlined in the NSA.

Automated Good Faith Estimate Compliance for FQHCs

MD Clarity’s Clarity Flow automates the process of sending GFEs with a high degree of accuracy. You can deliver good faith estimates through email, texts, or letters, keeping you in compliance with the No Surprises Act.

The patient-provider dispute resolution process can be expensive even if you win, so delivering accurate GFEs upfront is in your best interest. With Clarity Flow, your GFEs will be automatically generated based on the data in your system. This eliminates errors associated with manual data entry and GFE generation. Reach out today for a demo to see how Clarity Flow can streamline NSA compliance.

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