No Surprises Act
Understanding the No Surprises Act
The federal government enacted the No Surprises Act in December 2020 as part of broader legislation. In Pennsylvania, Governor Wolf signed an Executive Order to coordinate the implementation of this federal law. Under the No Surprises Act, health care providers are required by law to provide a good faith estimate of costs for services when scheduling care or upon patient request.
This is a developing issue, and PPA and APA are actively working to interpret and implement the nuances of this law. As Pennsylvania and other states enact specific regulations, additional information will be shared promptly.
Key Points About the No Surprises Act
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Applicability: The law applies to all health care providers acting under the scope of their professional license, not just psychologists. Both uninsured and self-pay patients are entitled to good faith estimates.
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Current Requirements: Providers must offer good faith estimates to uninsured and self-pay patients. This includes current patients who fall into these categories.
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Future Updates: Further guidance will clarify requirements for patients using insurance.
Good Faith Estimate Requirements
Timing of Estimates
| Appointment Scheduling Timeframe | Estimate Due By |
|---|---|
| At least 3 business days before the appointment | No later than 1 business day after scheduling |
| At least 10 business days before the appointment | No later than 3 business days after scheduling |
| Estimate requested without an appointment scheduled | No later than 3 business days after the request |
A new estimate must be provided if the patient reschedules.
Content of the Estimate
Good faith estimates must include:
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Patient’s name and date of birth
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Description of the primary service being provided (with date, if applicable)
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Itemized list of expected items or services
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Applicable diagnosis codes, service codes, and associated charges
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Provider’s name, National Provider Identifier (NPI), Tax Identification Number (TIN), and office location(s)
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List of separately scheduled items/services expected before or after the primary service
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CMS-specified disclaimers (see Appendix A for language)
Frequently Asked Questions
How do I provide a diagnosis code for someone I haven’t met?
You can use “TBD” for the diagnosis code section for new patients. If you later assign a diagnosis, update this information in subsequent estimates. You may also use ICD-10 Z-codes (e.g., Z63.0 for relationship problems).
How should estimates be handled for child patients?
Provide the good faith estimate to the parents of patients aged 13 or under. For patients aged 14-17, give the estimate to the person consenting to treatment.
What if multiple modalities are anticipated?
Include all relevant CPT codes for anticipated treatments, such as individual therapy, group therapy, or diagnostic interviews.
Do I need to provide rates per session and expected frequency?
Yes. The good faith estimate must include both the rates per session and the projected number and frequency of sessions. If recurring services are anticipated over a 12-month period, you may provide a single estimate detailing the scope, frequency, and total number of services expected.
What if the treatment plan changes?
Update the good faith estimate to reflect any significant changes in expected costs or treatment scope. This is especially important if changes may cause costs to exceed the original estimate.
Additional Resources
Disclaimer: This information has been compiled from APA, The Trust, and CMS. It does not constitute legal advice and should not replace personal legal consultation
| Appointment Scheduling Timeframe | Estimate Due By |
|---|---|
| At least 3 business days before the appointment | No later than 1 business day after scheduling |
| At least 10 business days before the appointment | No later than 3 business days after scheduling |
| Estimate requested without an appointment scheduled | No later than 3 business days after the request |