WEDI calls for delay in enforcement of provisions of No Surprises Act
The organization’s survey of providers finds lack of standards and workflows will hamper compilation of good-faith estimates for consumers.
New legal requirements for providers to give an estimated cost of patients’ medical services will be difficult to meet, particularly when multiple organizations are involved in a patient’s care, according to WEDI, the Workgroup on Electronic Data Interchange,
Meeting the requirements of the No Surprises Act, which was included as part of a Consolidated Appropriations Act passed late in 2020, will be challenging because there is no standardized process to enable the exchange of cost information among facilities, WEDI notes.
That burden particularly falls on a “convening provider or facility” that bears responsibility for contacting all providers participating in complex services, such as surgery, to get their good-faith estimates, or GFEs, compile them and deliver them to patients. The vast majority of respondents to a survey by WEDI say they’re not ready to comply. As a result, WEDI is asking regulators for delays in enforcement of provisions of the No Surprises Act.
Giving consumers better healthcare cost information before services are delivered is a critical component of a reformed healthcare system, many consumer advocates say. Arming consumers with cost information will help them make better decisions on their own healthcare, supporting comparison shopping and better awareness of costs.
“While the No Surprises Act includes much needed consumer protections against catastrophic ‘surprise’ bills, it also includes challenging data exchange provisions, such as the convening provider/facility requirement,” says Charles Stellar, WEDI’s president and CEO. Although the government is holding off full enforcement of the Act’s requirements until the end of the year, most providers don’t have the capability of complying, he adds, noting: “Currently, there is no standard format or established workflow to transmit data to or from the convenor.”
Challenges in compiling estimates
The Act says that when a service, such as surgery, requires the involvement of multiple providers or facilities, a “convening provider or facility” is responsible for contacting all other potential providers or facilities that may be involved in the patient’s service, requesting a good-faith estimate for their portion of the service, compiling those estimates and giving them to the patient if the patient is uninsured or self-pay.
Even defining which organization should be the convening provider or facility is difficult, according to nearly two-thirds (65.8 percent) of respondents to the WEDI survey. Only one out of nine (11.7 percent) said defining the convening facility or provider would be easy or very easy. Most respondents said it will be very difficult or difficult to identify all appropriate co-providers or facilities for specific medical services.
Some 91.5 percent of survey respondents say it will be difficult or very difficult for the convening provider or facility to collect good-faith estimates from other providers. And 89 percent of respondents said they expect it to be difficult or very difficult to comply with provisions of the No Surprises Act that require good-faith estimates to be provided to patients or their health plans within three days of being requested or the service being scheduled.
Not surprisingly, more than eight of 10 respondents (83 percent) expressed support for the government delaying enforcement of the requirement that a convening provider facility obtain good-faith estimates from other organizations “until there is a standardized data exchange process in place to community information.”
WEDI, which conducted its survey in May, received 273 responses. Nearly four in 10 responses came from what the organization defined as small providers or clinics, which WEDI believes would be especially challenged in meeting No Surprise Act requirements on a manual basis.
Standards work in early stages
Some organizations are working on data exchange methods that would automate components of data exchange needed to comply with the Act, says Robert Tennant, vice president of federal affairs for WEDI. For example, HL7’s Da Vinci Project – a program to accelerate the use of the Fast Healthcare Interoperability Resource, or FHIR, standard – is working on a solution that “is limited to the GFE component,” he says.
However, the Da Vinci Project is in the earliest stages of working on payer cost transparency. At least 15 components of the process for supplying good-faith estimates by FHIR lie outside of its initial work on code sets to support cost transparency.
In addition, the ANSI Accredited Standards Committee X12 is working on a use case implementation guide for its 837 standard that, Tennant says, “will provide specific, concise instructions for a GFE EDI message,” but while that standard “is expected to support the GFE, it won’t help with the convening provider transaction.”
In a comment letter issued last September, X12 noted the need for standardized solutions to enable data exchange for the No Surprises Act. “Worst case outcomes for this rule include having disparate solutions that each meet the intent of this rule put forward by various healthcare industry organizations or having a multitude of proprietary solutions endorsed by various health plans, vendors, or clearinghouses,” the letter noted. “The reason federal requirements call for solutions developed by ANSI-accredited standards developers is because those organizations are held to procedures that ensure significant consensus is achieved before standards are approved.”
That’s why WEDI conducted the survey six months before the scheduled enforcement date for the Act, Tennant notes.
“WEDI’s position is that, absent a standard or standardized workflow, the convening provider requirement should be delayed, or at a minimum, the current enforcement discretion should be extended until standards are in place,” he explains. “This delay, however, would not prevent a patient (self-pay for now) from reaching out to these co-providers separately and receiving a GFE.”