Good faith estimates: what uninsured patients can get and dispute

What a good faith estimate is

If you don't have health insurance, or you choose not to use it for a particular service, federal rules let you get a written estimate of what that care should cost before you get it. CMS calls this a good faith estimate. It is an itemized list of expected charges for scheduled care, such as the procedure and the facility fee.

The estimate matters twice: once when you decide whether to go ahead, and again when the bill arrives. If the bill is much higher, the estimate is what lets you dispute it.

Who can get one

According to CMS, you can get a good faith estimate if you aren't using health insurance to pay for the care, and either:

• you schedule the care at least three business days in advance, or

• you ask for an estimate, even before scheduling.

Tell the provider clearly that you are uninsured or not using your insurance. That statement is one of the conditions for the dispute process later, so it's worth making in writing, such as by email or through the patient portal.

When you should receive it

CMS sets the timing based on how far ahead the care is scheduled:

• Scheduled 3 to 9 business days ahead: the estimate should arrive within 1 business day.

• Scheduled 10 or more business days ahead: within 3 business days.

• Requested before scheduling: within 3 business days of your request.

• Scheduled 0 to 2 business days ahead: you aren't entitled to an estimate.

You can choose to receive it on paper or by email.

What it includes, and what it may leave out

CMS says the estimate should list the expected items and services related to your care. Each estimate covers one provider or facility. For surgery, for example, you might need one from the surgeon and one from the hospital.

CMS also notes what an estimate may not include:

• services scheduled separately, such as appointments before surgery or physical therapy afterward;

• services from other providers;

• services no one expected, such as an extra procedure that became necessary during care.

Read the estimate before your appointment. If something you expect isn't listed, such as anesthesia or a pathology test, ask whether it will be billed separately and request an estimate from that provider too.

A sample estimate, decoded

Sample good faith estimate · Northgate Outpatient Surgery (synthetic)

Patient: self-pay · Scheduled service: colonoscopy with possible biopsy · Date: 09/15

Facility fee $1,450.00 · Supplies $180.00 · Recovery room $320.00 · Total estimate $1,950.00

Not included: physician fees, anesthesia, pathology

The estimate covers only the facility. The doctor, the anesthesia provider and the lab that reads any biopsy will bill separately, so ask each of them for their own estimate. Keep all of them together.

If the bill is much higher: the dispute process

CMS runs a patient-provider dispute process for uninsured and self-pay patients. You can use it only if all of these apply:

1. You didn't have, or didn't use, insurance for the care.

2. You told the provider before the care that you weren't using insurance.

3. The care was on or after January 1, 2022.

4. You received a good faith estimate at least three days before your scheduled appointment.

5. The initial bill is dated within the last 120 calendar days.

6. The provider or facility charged at least $400 more than its good faith estimate.

How the $400 is counted

The comparison is per provider or facility: the bill from one provider against that provider's own estimate. Using the sample above, a facility bill of $2,400 would be $450 over the facility's $1,950 estimate.

What you file

CMS asks for the good faith estimate with the provider's contact information, the bill, and a $25 fee. The fee is non-refundable, and the dispute doesn't start until it is paid. If the decision goes your way, CMS says the $25 is subtracted from what you owe the provider. CMS says not to send original documents.

Protections while the dispute is open

CMS says that during the dispute the provider can't send the bill to collections or threaten to, can't collect existing late fees until the dispute ends, and can't retaliate against you. If the bill is already in collections, collection must stop until the dispute is resolved.

How it ends

An independent reviewer looks at the bill. If the reviewer finds the extra care was appropriate, the bill stays the same. CMS says your costs won't go up because you disputed. If you and the provider agree on an amount during the process, the provider must reduce the bill by at least $12.50 and notify the reviewer.

If you didn't get an estimate at all

You can't use the dispute process without a good faith estimate. CMS says that if you should have received one and didn't, you can submit a complaint. You may still owe the bill, but the complaint helps make sure future patients get estimates. You can also ask the provider about a discount, a payment plan or financial assistance.

Practical tips

• Ask for estimates early, and from every provider involved.

• Keep the estimate, the bill and any messages in one folder, digital or paper.

• Watch the 120-day window. It runs from the date of the initial bill, so put the deadline in your calendar the day the bill arrives.

• For questions, CMS lists the No Surprises Help Desk at 1-800-985-3059, with help in more than 350 languages.

Compare your estimate with your bill

When EasyToDecode opens, you'll be able to upload a good faith estimate and the bill that followed and see them compared line by line, each figure quoted from the page, with the gap calculated, the 120-day date noted and questions ready for the provider. See how it works or join the waitlist.