WEDI to HHS – Industry lacks standards for No Surprises Act

Standards and essential workflows are lacking, and a collaborative approach to implementation would increase chances for success, group contends.

Standards in Healthcare
“All stakeholders will face almost impossible hurdles meeting the legislation’s deadlines to get GFEs and AEOBs to the patient,” says WEDI president & CEO, Charles Stellar.

The Workgroup for Electronic Data Interchange is calling for a federal agency to delay the implementation of data exchange requirements for the No Surprises Act, saying the industry lacks standards to meet requirements, and needs flexibility and time to ensure success.

Testing, cross-industry initiatives and a phased-in implementation are key components of what WEDI calls a necessary “glide path” for achieving success in hitting the goals of the No Surprise Act, which was passed to ensure that patients are not burdened by unexpected medical bills and that consumers have improved access to information on healthcare costs.

The WEDI letter, to Xavier Becerra, secretary of the Department of Health and Human Services, outlines “significant concerns regarding the ability of stakeholders to meet the Good Faith Estimate (GFE) of care costs; a provision requiring a “convening provider” to gather cost estimates from all entities providing care for patients receiving treatment from multiple providers; and requirements for an Advanced Explanation of Benefits, which would include an accurate estimate of how much expense payers will cover for services.

Challenges of the act

The No Surprises Act requires healthcare organizations provide uninsured, self-pay and commercially insured patients with a cost estimate for their medical service. When a service involves multiple providers – for example, for surgical procedures – a convening provider is responsible for all other potential providers that may be involved in the patient’s service, requesting a GFE for their portion of the service and compiling those GFEs. The convening provider then either would give them to the patient if the patient is uninsured or self-paying, or transmitting them to the patient’s health plan for development of an AEOB.

“Without established standards and automated workflows, providers will face almost insurmountable challenges identifying who the convening provider should be, who the appropriate co-providers should be, how to collect GFEs from these co-providers, and how to transmit GFEs to the patient’s health plan,” noted Charles Stellar, WEDI president and CEO.

“At the same time, health plans will experience significant difficulties in collecting the GFE information necessary to produce the AEOB from providers and communicating to providers when GFE information is missing,” Stellar added in the letter. “All stakeholders will face almost impossible hurdles meeting the legislation’s deadlines to get GFEs and AEOBs to the patient.”

Gradual approach

Instead of setting an arbitrary, cut-and-dried deadline, WEDI suggests a gradual implementation plan that involves collaborative efforts between federal agencies and the private sector.

“Deploying an appropriate No Surprises Act data exchange glidepath – developed through a partnership between the federal government and the private sector – will ensure that patients receive the cost information they need to guide their healthcare decisions while minimizing administrative burdens on providers and health plans,” Stellar stated.

Recommendations in WEDI’s letter include:

  • Extending the enforcement discretion for the convening provider provision of the Act.
  • Identifying appropriate No Surprises Act GFE and AEOB data exchange standards, and automated workflows for providers and health plans.
  • Harmonizing No Surprises Act GFE and AEOB data exchange standards with current and forthcoming administrative transactions.
  • Adopting No Surprises Act GFE and AEOB data exchange standards only after they have been pilot tested by appropriate industry stakeholders.
  • Employ a staged approach to meeting the data exchange requirements of the Act until standards have been fully adopted by the industry.
  • Work with industry partners to educate patients and industry stakeholders on the No Surprises Act opportunities and requirements.

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