Is a Good Faith Estimate Required for a Filler or Neuromodulator Treatment?
The No Surprises Act (NSA) took effect in January 2022. And as I’ve discussed in previous articles,1 many aesthetic physicians could not agree whether this Trojan horse of health care legislation even applied to aesthetic services or just to uninsured (self-pay) individuals getting medically necessary, but elective, services. It is my belief that the verdict appears to be that aesthetic services are included in the Act—or, at the very least, not excluded. (See sidebar “The No Surprises Act” for a history of how and when the NSA went into effect.)
THE NO SURPRISES ACT
In December 2020, Congress passed the No Surprises Act (NSA)2 as part of a larger COVID relief package. It went into effect on January 1, 2022. The NSA, as the name implies, had one overarching goal: to reduce the occurrence of surprise bills after a medical service or procedure. It does this in three broad ways:
Reducing surprise bills when patients are using insurance in emergency situations
Reducing surprise bills when patients are utilizing out-of-network benefits in non-emergent scenarios by providing the patient with a preoperative estimate and obtaining their signed consent to balance bill
Reducing surprise bills when patients are not using insurance because they are uninsured (self-pay) and providing the patient with a Good Faith Estimate3 of their expected out-of-pocket expenses.
The original Act and subsequent regulations issued by the Centers for Medicare & Medicaid Services (CMS) never explicitly stated that aesthetics came under the purview of the NSA. However, they never excluded it, either. And as I’ve written before, I don’t believe aesthetics was on the radar of either entity (Congress or CMS) when the law and regulations were designed.
THE GOOD FAITH ESTIMATE (GFE)
CMS has issued several clarifications of the NSA and GFE. In those clarifications, the agency has not taken the opportunity to exempt aesthetics. So if aesthetic providers are subject to the law, but the law doesn’t delineate when it applies to aesthetics, how do we know when we need to provide a GFE to our patients? Which treatments or appointments require an estimate?
The GFE requires the provider to give the patient a written/typed estimate that includes the patient demographics, provider’s EIN and NPI number, CPT code (if one exists for the procedure), and an ICD-10 code. The estimate must also include all reasonably expected costs associated with the procedure and a disclaimer, written by CMS, that says the patient can launch a dispute against the provider if a post-procedure bill arrives that’s $400 greater than the GFE.
Based on an update from CMS on April 5,4 we can extrapolate when a GFE is needed. The general rule seems to be that a GFE is required if there are:
- multiple providers providing a service
- multiple sessions.
MULTIPLE PROVIDERS
If a procedure is scheduled in an in-office operating room, ambulatory surgery center (ASC), or hospital and the patient is paying out of pocket, then a GFE is needed. Because multiple providers will perform the services, the estimate must include all constituent fees. For example, if performing a breast augmentation at an ASC, then the “multiple providers” include the surgeon, anesthesiologist, and surgery center fees. The estimate must also include all other reasonably expected costs, such as the implants, post-op garments, and any other potential post-op care items.
This could also apply to Mohs surgery. If the patient is paying cash for the dermatologist’s excision, reconstruction, and pathological evaluation, they would need a GFE with all of those reasonably expected fees.
MULTIPLE SESSIONS
Do we need to give a patient a GFE if they’re coming in for a filler or neuromodulator? According to an April 5 update, the answer appears to be no.
In the example provided by CMS, “if an individual arrives to schedule same-day laboratory testing services, the laboratory testing provider or facility is not required to provide the individual with a GFE.” This suggests that, if someone comes in for a “one-off” appointment for an injection, a GFE is not required.
The need for a GFE is, however, triggered if there are previously scheduled recurring items or services. The example provided is for “periodic counseling services or physical therapy services.”
In the case of an aesthetic practice or medspa, it seems reasonable that, if a patient is scheduled for multiple sessions as a package, membership, or subscription (i.e., laser hair removal, microneedling, subscription-based membership programs), a GFE is required. CMS goes on to clarify that a GFE is not needed before each individual treatment but can cover all expected treatments for a period of 12 months. After that, a new GFE is needed for each additional year.
Not Worth the Risk
While the regulations don’t mention aesthetics, the spirit of the NSA is clearly to reduce surprise bills by making pricing information available ahead of time. But if you’re not convinced the NSA applies to aesthetics, proceed at your own risk. The penalty for each violation is $10,000!
For additional information on compliance with the No Surprises Act, visit NoSurprisesAct.com
1. https://modernaesthetics.com/articles/2022-mar-apr/does-the-no-surprises-act-apply-to-aesthetic-services-1?c4src=search:feed
2. https://nosurprisesact.com
3. https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Guidance-Good-Faith-Estimate-Patient-Provider-Dispute-Resolution-Process-for-Providers-Facilities-CMS-9908-IFC.pdf
4. https://www.buildmybod.com/blog/cms-faqs-about-consolidated-appropriations-act-2021-implementation-good-faith-estimates-gfe-for-uninsured-or-self-pay-individuals-part-2/
5. www.buildmyhealth.co
6. https://www.newsweek.com/winning-victory-cost-transparency-health-care-opinion-1687849
7. https://modernaesthetics.com/search?q=Jonathan+kaplan
8. https://medcitynews.com/category/medcity-influencers
9. https://www.medicaleconomics.com/search?searchTerm=Jonathan%20kaplan
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