A flurry of stakeholder complaints around the "convener" requirement for good faith estimates (GFE) has put pressure on CMS to take action.
Several major health care industry groups have issued statements in recent days calling for CMS to make changes related to its convener requirement, which asks providers to create charge estimates for some patients that cover not only their own services but those of downstream providers, according to Part B News.
For example, the American Hospital Association (AHA) executive vice president Stacey Hughes asked CMS to extend its "enforcement discretion" on the convener requirement beyond next January 1.
"Due to the lack of currently available automated solutions, this process would require a significant manual effort by providers, which would undoubtedly result in the convening provider being unable to meet the short statutory timeframes for delivering good faith estimates to the patients and could also lead to inadvertent errors," Hughes wrote.
The American Medical Group Association (AMGA) also sent an open letter to CMS saying GFE requirements have resulted in significant challenges for providers to effectively schedule, coordinate, and deliver care.
AMGA members report completing more than 45,000 GFEs in a month and expect that number will increase, according to the association.
"The current GFE requirements impose additional stress to an already strained healthcare workforce," said AMGA president and CEO Jerry Penso. "CMS should reform the process so that the estimates provide the information patients need without creating new administrative obstacles for providers to overcome."
It’s unclear how many organizations have faced a significant impact from the convener requirement, but Darryl Drevna, AMGA’s senior director of regulatory affairs, says some AMGA members who are part of health systems have been hit hard. Some members have told Drevna their systems have generated 45,000 to 50,000 GFEs since the policy took effect January 1.
When it comes to the "convener" requirement, which is all tied to the No Surprises Act, experts predict CMS will bend on the requirement but is unlikely to remove it entirely, according to Part B News.
Experts and health care personnel seem to agree the convener job poses difficulties.
According to a survey from the Workgroup for Electronic Data Interchange (WEDI), formal advisors to HHS on health IT, 86% of respondents say it would be very difficult or difficult for providers and facilities to determine who should be the convening provider or facility.
Some 83% of respondents supported delaying the requirement "until there is standardized data exchange process in place to communicate information between convening providers and co-providers/co-facilities."
Paul Johnson, the former Phoenix mayor who runs the care coordination company Redirect Health in Scottsdale, Arizona, told Part B News that his company also operates a clinic that has to follow policies that have stemmed from the No Surprises Act, and "from the clinic side these rules are really hard and we’re struggling to implement them."
However, Johnson also acknowledges that "from our customer's standpoint, balance billing and disclosure are high priority issues" and believes the convener requirement can be doable if all parties are cooperating.
As a care coordinator he routinely works with hospitals on billing for multi-provider service costs and finds that “when we work with hospitals around the country, we find a lot of them are very cooperative about helping us get a price and editing downstream costs,” Johnson says.
"Granted, a lot of others try to play games—they give us a price and send a balance bill to our customer." Johnson thinks for some hospitals this is still "a standard course of business... But [the No Surprises Act] is helping address that system issue."
Other experts point to additional issues that have to be squared away. "Groups within the provider community have been communicating both formally and informally with CMS about these requirements," David McLean, partner with Hall Booth Smith PC in Atlanta told Part B News.
"For example, take mental health providers. It’s very difficult to put together a GFE for their services because you’re looking at an open-ended term of illness and you can’t really create an upfront estimate," McLean said.
Drevna says the technical issue is a major part of the convener problem.
"There's no way to automate this process," he says. "Our EHRs don’t have the capability to transmit this sort of information or even communicate provider-to-provider when systems aren’t set up to share billing details provider-to-provider. They’re designed to work with payers."
Read more about this analysis and if experts see CMS relenting on this requirement on our sister publication Part B News.
Amanda Norris is the Director of Content for HealthLeaders.