Major Medical Groups Pen Complaints of GFE ‘Agree’ Requirement

A flurry of stakeholder complaints about the convener requirement for Good Faith Estimates (GFE) has put pressure on CMS to act.

Several major health care industry groups have released statements in recent days calling on CMS to make changes related to its Convenor Requirement, which asks providers to create fee estimates for certain patients that not only cover their own services, but those of downstream suppliers, according to Part B News.

For example, the executive vice president of the American Hospital Association (AHA), Stacey Hughes asked the CMS to extend its “application discretion” on the summoner requirement beyond next January 1.

“Due to the lack of automated solutions currently available, this process would require significant manual effort on the part of providers, which would undoubtedly prevent the calling provider from meeting the short legal deadlines for providing good faith estimates to patients and could also lead to unintended errors,” wrote Hughes.

The American Medical Group Association (AMGA) also sent an open letter to CMS claiming that GFE requirements have resulted in significant challenges for providers to effectively plan, coordinate and deliver care.

AMGA members say they have completed more than 45,000 GFEs in a month and expect that number to grow, according to the association.

“Current GFE demands are placing additional stress on an already stretched healthcare workforce,” said AMGA President and CEO Jerry Penso. “CMS should reform the process so that estimates provide the information patients need without creating new administrative hurdles for providers to overcome.”

It’s unclear how many organizations have faced a significant impact from the convening requirement, but Darryl Drevna, AMGA’s senior director of regulatory affairs, says some AMGA members who are part of the systems of health have been hit hard. Some members told Drevna that their systems have generated 45,000 to 50,000 GFEs since the policy took effect on Jan. 1.

As for the “convener” requirement, which is entirely tied to the law unsurprisingly, experts predict that CMS will comply with the requirement, but it is unlikely to remove it entirely, according to Part B News.

Experts and health personnel seem to agree that the job of convener poses challenges.

According a survey by the Electronic Data Interchange Working Party (WEDI), HHS Official Health Informatics Advisors, 86% of respondents say it would be very difficult or difficult for providers and facilities to determine who the organizing provider or facility should be.

Some 83% of respondents supported deferring the requirement “until there is a standardized data exchange process in place to communicate information between convening vendors and co-vendors/co-facilities.” “.

Paul Johnson, the former mayor of Phoenix who runs the care coordination company Redirect Health in Scottsdale, Arizona, told Part B News that his company also operates a clinic that must follow policies arising from the No Surprises Act, and “from the clinical side these rules are really difficult and we have a hard time implementing them.”

However, Johnson also recognizes that “from the perspective of our customers, billing and balance disclosure are high priority matters” and believes the organizer requirement can be achievable if all parties cooperate.

As a Care Coordinator, he regularly works with hospitals on cost billing for multi-vendor services and finds that “when we work with hospitals across the country, we find that many of them are very cooperative in help us get a price and change the costs downstream,” says Johnson.

“Certainly many others try to play games – they give us a price and send a balance invoice to our customer.” Johnson thinks for some hospitals it’s still “a normal course of business… But [the No Surprises Act] help solve this system problem.”

Other experts report additional issues that need to be addressed. “Groups within the vendor community have communicated both formally and informally with CMS about these requirements,” David McLean, partner at Hall Booth Smith PC in Atlanta, told Part B News.

“For example, take mental health providers. It’s very difficult to set up a GFE for their services because you’re looking at an indefinite duration of illness and you can’t really create an initial estimate,” McLean said.

Drevna says the technical problem is an important part of the organizer’s problem.

“There’s no way to automate this process,” he says. “Our EHRs don’t have the capability to pass this type of information or even communicate vendor-to-vendor when the systems aren’t set up to share vendor-to-vendor billing details. They’re designed to work with payers .”

Read more about this analysis and whether experts see CMS backing down on this demand on our sister publication Part B News.

Amanda Norris is Revenue Cycle Writer for HealthLeaders.

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