A flurry of stakeholder complaints around the “convener” requirement for good faith estimates (GFE) that are a product of the No Surprises Act of 2020 has put pressure on CMS to take action. Experts predict CMS will bend on the requirement but is unlikely to remove it entirely.
Several major health care industry groups have issued statements in recent days calling for CMS to make changes related to this convener requirement, which asks providers to create charge estimates for some patients that cover not only their own services but those of downstream providers (PBN 1/10/22).
For example, the American Hospital Association (AHA) executive vice president Stacey Hughes asked CMS administrator Chiquita Brooks-LaSure to extend its “enforcement discretion” on the convener requirement beyond next Jan. 1, according to a June 6 open letter.
“Due to the lack of currently available automated solutions, this process would require a significant manual effort by providers, which would undoubtedly result in the convening provider being unable to meet the short statutory time frames for delivering good faith estimates to the patients and could also lead to inadvertent errors,” Hughes wrote.
The American Medical Group Association (AMGA) also sent an open letter to Brooks-LaSure from its president and CEO Jerry Penso, M.D. The letter includes examples of clinical cases that make the creation of accurate GFEs burdensome —for example, “a radiological exam that identifies a suspect abnormality that could result in any number of reasonably expected outcomes and treatment plans.”
Assessing the impact of GFEs
It’s unclear how many organizations have faced a significant impact from the convener requirement, but Darryl Drevna, AMGA’s senior director of regulatory affairs, says some AMGA members who are part of health systems have been hit hard. Some members have told Drevna their systems have generated 45,000 to 50,000 GFEs since the policy took effect Jan. 1, 2022.
Experts and health care personnel seem to agree the convener job poses difficulties. According to a survey from the Workgroup for Electronic Data Interchange (WEDI), formal advisors to HHS on health IT, 86% of respondents say it would be very difficult or difficult “for providers and facilities to determine who should be the ‘convening provider/facility.’” Some83% of respondents supported delaying the requirement “until there is standardized data exchange process in place to communicate information between convening providers and co-providers/co-facilities.”
Paul Johnson, the former Phoenix mayor who runs the care coordination company Redirect Health in Scottsdale, Ariz., says his company also operates a clinic that has to follow policies that have stemmed from the No Surprises Act, and “from the clinic side these rules are really hard and we’re struggling to implement them.”
However, Johnson also acknowledges that “from our customers’ standpoint, balance billing and disclosure are high priority issues” and believes the convener requirement can be doable if all parties are cooperating. As a care coordinator he routinely works with hospitals on billing for multiprovider service costs and finds that “when we work with hospitals around the country, we find a lot of them are very cooperative about helping us get a price and editing downstream costs,” Johnson says. “Granted, a lot of others try to play games — they give us a price and send a balance bill to our customer.” Johnson thinks for some hospitals this is still “a standard course of business… But [NSA] is helping address that system issue.”
Other experts point to additional issues that have to be squared away. “Groups within the provider community have been communicating both formally and informally with CMS about these requirements,” says David McLean, partner with Hall Booth Smith PC in Atlanta. “For example, take mental health providers. It’s very difficult to put together a GFE for their services because you’re looking at an open-ended term of illness and you can’t really create an upfront estimate.”
Drevna says the technical issue is a major part of the convener problem “There’s no way to automate this process,” he says. “Our EHRs don’t have the capability to transmit this sort of information or even communicate provider-to-provider E-Systems aren’t set up to share billing details provider-to-provider. They’re designed to work with payers.”
Rajesh Voddiraju, founder and group president at Health iPASS, a Sphere company in Chicago, sees an obstacle in the eligibility “black box” that hides the enrollment or insurance status of providers from practices that are not subscribed to the same plan. “We need a registry that democratizes this information so that anyone in the chain, including the patient, will be able to examine all the providers’ statuses,” he says.
Voddiraju hopes that “market movers” in the industry will push for greater transparency. “The government should expand the administrative simplification mandate [to make] payers provide network participation status,” he says.
Will CMS relent?
In recent months, CMS has been bombarded by lawsuits related to NSA rules (PBN 3/7/22). In response, the agency “has promised that it will address all of the concerns raised in the challenges to the interim final rule early this summer,” McLean says. “But we’ve yet to have an indication of when a revised rule is to be expected other than this sort of nebulous promise.”
Experts tell Part B News they believe CMS is operating in good faith, and that provider organizations are on board with the general mission of preventing surprise billing.
“CMS implemented this essentially on an emergency basis in their interim final rule — like, this is something that’s so critical it needs to be done right away,” Drevna adds. “So it came up fast and caught everyone off guard.”
“I think generally there’s support in the provider community [for the idea] that we need to avoid surprise bills to patients and have price transparency so they can make good decisions,” McLean says. “The litigation and all these other disputes revolve around the mechanics of how best to do that.”
By: Roy Edroso
From: Part B News