CMS Update: No Surprises Act’s AEOB and GFE Provisions

Implementation of the No Surprises Act – or NSA – continues to slowly but surely drive evolution of the healthcare landscape in the U.S.

Central to the NSA’s aim of protecting patients from unexpected medical bills are two key components of the law that have yet to be executed or enforced: the Advanced Explanation of Benefits (AEOB) and the Good Faith Estimate (GFE), both designed to provide patients with transparency and clarity regarding their medical expenses.

As a quick refresher, the NSA’s AEOB provision requires healthcare providers and insurers to furnish patients with an estimate of their out-of-pocket costs before they receive non-emergency medical care.

This preemptive disclosure is intended to empower patients to make informed decisions about their healthcare by allowing them to anticipate and plan for potential expenses, fostering a more patient-centric approach to healthcare.

Relatedly, the GFE component of the NSA mandates that healthcare providers furnish patients with a written estimate of the expected charges for scheduled services. This estimate must include the anticipated costs of medical services, as well as any associated fees from healthcare providers and facilities, enabling patients to compare prices across different healthcare providers and make informed decisions based on quality and affordability.

However, because neither of these provisions of the NSA have been implemented, neither health plans nor providers are required to comply with them, as, for the most part, enforcement of these requirements has been deferred by the Centers for Medicare & Medicaid Services (CMS) pending future rulemaking.

While Congress repeatedly presses regulators to improve and accelerate implementation efforts pertaining to the NSA, CMS recently publicized some transparency of its own in a critical update on the agency’s progress made toward AEOB and GFE rulemaking and official enactment.

Here are a few takeaways from the update that I found most illuminating:

1. First, CMS claims to have gained a more nuanced understanding of the business processes, communication norms, technical resources, and interdependencies of the stakeholders who would be involved in generating insured GFEs and AEOBs.

2. Second, CMS also says that certain perceived challenges have brought to light the need for an efficient, automated way to process GFEs, after concerns about timing, liability, and content of GFEs were expressed.

3. Third, CMS now recognizes that the development of data standards supporting the exchange of GFE information between providers is critical to implementing insured GFE and AEOB requirements. As such, new standards may need to be established to ensure successful implementation of AEOB requirements. Further, CMS feels that, as of now, HL7 Fast Healthcare Interoperability Resource (FHIR)-based data exchange standards and application programming interfaces (APIs) hold promise as the basis for developing efficient and effective GFE and AEOB transmission methods.

4. And finally, CMS notes that it is composing additional educational materials for providers on these NSA provisions. For example, in spring of this year, the agency plans to publish a new set of FAQs that address common provider inquiries on AEOBs and GFEs.

As implementation of the No Surprises Act continues progressing, stakeholders across the healthcare industry are clearly working to streamline AEOB and GFE processes, enhance transparency, and improve the overall patient experience. But as we can plainly see from CMS’s latest update, we are still quite a ways off from standard use in the industry of the AEOB or GFE components of the law.

Nevertheless, the AEOB and GFE provisions of the NSA represent significant steps toward enhancing transparency and empowering patients in the healthcare decision-making process.

As these provisions become fully integrated into the healthcare system, the hope is that it provides patients with greater clarity and predictability regarding their medical expenses, ultimately leading to improved outcomes and experiences.

The thousand-pound question that remains is whether these hopes will ever be fully realized….and if so, when.