Newsletter started 1/3/2022. Updated 1/5/2022.
Hello IMHCA Members,
We are here to synthesize some information and provide resources in one place. This information does not take the place of legal advice. Thanks to our board and membership for contributing to this guide. While following the rules is always important, the primary ethical goal is to provide good care. It seems unlikely that those acting in good faith will be disciplined for rule violations if there is a good, recorded effort and the actions do not present a risk of harm to the patient or the public.
Added on 1/11/2021 the Florida Mental Health Counselors Association has provided an informational webinar: https://youtu.be/Y3FHjn5HNQI
This site has a link to a PDF that is very helpful found here. Though this document is long, it breaks down the act in it’s entirety and offers links to the example forms covered in this resource guide.
On July 1, 2021, the “Requirements Related to Surprise Billing; Part I,” interim final rule was issued to restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.
On September 30, 2021, a second interim final rule was issued and is open for public comment. The “Requirements Related to Surprise Billing; Part II” rule provides additional protections against surprise medical bills, including:
Together, these lay the groundwork to provide consumers with protection against surprise billing, starting in 2022. Learn more about how these rules help consumers.
On November 17, 2021, a third interim final rule was issued and is open for public comment. The “Prescription Drug and Health Care Spending” rule implements new requirements for group health plans and issuers to submit certain information about prescription drug and health care spending. This includes, among other things, information on the most frequently dispensed and costliest drugs, and enrollment and premium information, including average monthly premiums paid by employees versus employers.
The Centers for Medicare and Medicaid Services (CMS) have provided instructions and a sample good faith estimate template (PDF, 163KB). A good faith estimate (PDF, 130KB) must contain the following information in clear and understandable language:
The required disclaimers are included in the CMS template cited above.
ACA: “Starting January 1, 2022, behavioral health care providers will be required by law to give uninsured and self-pay clients a good faith estimate of costs for services when scheduling care or when the client requests an estimate.”
APA: “Beginning January 1, 2022, psychologists and other health care providers will be required by law to give uninsured and self-pay patients a good faith estimate of costs for services that they offer, when scheduling care or when the patient requests an estimate…What providers and what services are subject to this rule? ‘Provider’ is defined broadly to include any health care provider who is acting within the scope of the provider’s license or certification under applicable state law. Psychologists meet that definition.”
AAMFT: “What providers and covered services concerning Good Faith Estimates does the No Surprise Billing Act apply to? Marriage and Family Therapists meet the definition for provider. The Interim Final Rules define the term ”health care provider’ to mean a physician or other health care provider who is acting within the scope of practice of that provider’s license or certification under applicable state law. Items and services for which the good faith estimate must be given must include all encounters, procedures, medical tests, substance use disorder, mental health, and fees (including facility fees), provided or assessed in connection with the provision of health care.”
The No Surprises Act specifically requires counselors to include “applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service” in good faith estimates furnished for all uninsured/private pay clients (or for insured clients who request a good faith estimate). A good faith estimate must be issued prior to the first appointment with the client (i.e., within 1 business day if the client’s appointment is 3 to 9 business days away or within 3 business days if the client’s appointment is 10 or more business days away). However, the AMHCA Code of Ethics requires counselors to use multiple sources of data when diagnosing clients. We can’t diagnose a client we haven’t even seen yet. I think that the key word in the law is “applicable.” In other words, there is no “applicable diagnosis” to place in a good faith estimate prior to the first appointment because the client has not yet been diagnosed. For this reason, in my practice we are implementing the law thusly: When the initial appointment is scheduled, we provide a good faith estimate for the 1st appointment only that uses the diagnostic code Z03.89 (i.e, the ICD-10 code for “no diagnosis.” After the initial appointment, we provide a 2nd good faith estimate for ongoing therapy that includes the provisional diagnosis as well as the appropriate CPT codes (i.e., individual vs. family therapy, for example), as we would need to have had the initial appointment already in order to make that determination. I also think it is important to note that some clients do not have “disorders” as diagnoses and instead will have diagnostic codes that come from the final chapter of Section II of the DSM-5 (i.e., z-codes and similar codes known as “other conditions that may be a focus of clinical attention”).
This article includes notes about how to interpret the rule as well as scenarios to consider.