Prepared by: Carlos Arce, Esq.
Florida Healthcare Law Firm
The United States Department of Health and Human Services (“HHS”) released that more than 90,000 claims were filed in April 2022 through the independent dispute resolution portal via CMS’s website.[1] This has caused an overload in submissions which CMS was not prepared to address.
CMS has opened a rulemaking style “frequently asked questions” portal where providers can submit questions for answers. A few of these questions include the following: 1) Are providers or facilities required to provide a Good Faith Estimate (“GFE”) to individuals who schedule a same-day appointment or are walk-ins? CMS answered, “No. The requirement to provide a GFE to an uninsured (or self-pay) individual under 45 CFR 149.610 is not triggered upon scheduling an item or service if the item or service is being scheduled fewer than 3 business days before the date the item or service is expected to be furnished. For example, if an uninsured (or self-pay) 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; and 2) How do providers and facilities address situations where unforeseen items or services that were not otherwise scheduled in advance are furnished during a visit? CMS answered, “The interim final rules do not require the GFE to include charges for items or services that could not have been reasonably expected. A GFE provided to uninsured (or self-pay) individuals must include an itemized list of items or services that are reasonably expected to be furnished, grouped by each provider or facility, for that period of care.
As noted above the GFE is effective and operating under its interim final rules, which mean that the law is in effect, but changes are being done to it as we speak. There is lawsuit pending in Texas, where the validity of the independent dispute resolution is being questioned. We expect to see changes in 2023.
For now these are the top codes which are being disputed per the data CMS released: Emergency department services (CPT codes 99281-99288), Radiology (70010-79999), Anesthesia (00100-01999), Surgery (10004-69990), Pathology and lab (80047-89398), Neurology and neuromuscular procedures (95700-96020), Critical care services (99291-99292), and Cardiovascular procedures (92920-93799), Hydration, therapeutic, prophylactic, diagnostic injections and infusions, and chemotherapy and other highly complex drug or highly complex biologic agent administration (96360-96549).
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Attorney Carlos Arce works with the Florida Healthcare Law Firm in Delray Beach, FL. He has deep experience with bodily injury trial work and in health law. Carlos has handled multi-million-dollar healthcare transactions and serves as out-of-house counsel to various small to large types of healthcare entities. He can be reached via email at [email protected] or by calling 561-455-7700.
[1] Top No Surprise Act CPT Code Disputes, Patsy Newitt, Becker’s ASC Review: https://www.beckersasc.com/asc-news/top-no-surprises-act-cpt-code-disputes.html?utm_campaign=asc&utm_source=website&utm_content=latestarticles