Essential standards and workflows are lacking, and a collaborative approach to implementation would increase the chances of success, the group argues.

“All stakeholders will face nearly impossible hurdles to meet within the legislation timelines to get GFEs and AEOBs to the patient,” said Charles Stellar, President and CEO of WEDI.

The Electronic Data Interchange Task Force is asking a federal agency to delay implementing data interchange requirements for law without surprise, saying the industry lacks standards to meet the requirements and needs flexibility and time to ensure success.

Testing, cross-industry initiatives and phased implementation are key elements of what WEDI calls a “glide of descent” needed to successfully meet the goals of the unsurprising law, which was passed to ensure that patients do not not be overwhelmed by the unexpected. medical costs and that consumers have better access to information on health care costs.

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 collect cost estimates from all entities providing care to 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 the services.

The stakes of the act

The No Surprises Act requires healthcare organizations to provide uninsured, self-paid, and commercially insured patients with an estimate of the costs of their medical service. Where a service involves multiple providers – for example, for surgical procedures – a convening provider is responsible for all other potential providers who may be involved in the patient’s service, requesting a GFE for their part of the service and compiling these GFE. The convening provider would then give them to the patient if the patient is uninsured or self-pays, or forward them to the patient’s health plan for development of an AEOB.

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

“At the same time, health plans will experience significant challenges in collecting the GFE information needed to produce the AEOB from providers and communicating to providers when GFE information is missing,” Stellar added in the letter. “All stakeholders will face nearly impossible hurdles to meet within the timeframes of the legislation to get GFEs and AEOBs to the patient.

Phased approach

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

“Deployment of an appropriate No Surprises Act data exchange plan – 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 decisions in health care while minimizing administrative burdens for providers and health plans,” Stellar said.

Recommendations from the WEDI letter include:

  • Expand the enforcement discretion of the Convening Provider Act provision.
  • Identification of appropriate No Surprises Act GFE and AEOB data exchange standards, and automated workflows for providers and health plans.
  • Harmonization of GFE and AEOB No Surprises Act data exchange standards with current and future administrative transactions.
  • Adopt the GFE and AEOB No Surprises Act data exchange standards only after they have been tested by the appropriate industry stakeholders.
  • Adopt a phased approach to meet the data exchange requirements of the Act until the standards have been fully adopted by industry.
  • Work with industry partners to educate patients and industry stakeholders on the opportunities and requirements of the law without surprises.