Good faith estimates for self-pay patients: what your website and front desk must do

Many independent practices see patients who pay for care themselves: med spas, dental offices with uninsured patients, cash-pay chiropractic and integrative clinics, and any practice where a patient chooses not to use insurance. If that describes some of your patients, a federal rule from the No Surprises Act affects your website, your scheduling scripts and your price marketing.

The rule is the good faith estimate requirement at 45 CFR 149.610. This guide explains what it asks of a practice in plain words, where it touches marketing, and how to keep your advertised prices and your estimates telling the same story. If your website has a price calculator, our guide to cost estimator tools on a practice website explains how it sits next to the good faith estimate. Patients with insurance who pay you directly and send a superbill to their plan are covered in our guide to advertising an out-of-network practice. For bookings that arrive through a third-party site, see listing a practice on price comparison and booking marketplaces.

Who the rule covers

The rule applies to health care providers and facilities when a patient is uninsured, or is insured but does not plan to have a claim submitted to their plan. The regulation calls these patients uninsured (or self-pay) individuals. CMS sums it up for patients this way: usually, if you are not using health insurance to pay for your care, your provider must give you a good faith estimate of expected charges if you request one or schedule services at least 3 business days in advance.

Under 149.610, the practice that receives the request or schedules the main service is the convening provider. It must ask about insurance status when scheduling or when someone asks about cost, and it must tell patients that estimates are available.

The notice: your website, office and phone

This is the part that lands directly on your marketing. Section 149.610(b)(1) says the convening provider must inform uninsured or self-pay patients of the availability of a good faith estimate, and that the information must be:

• Written in a clear and understandable manner, prominently displayed and easily searchable from a public search engine on your website, in the office, and on-site where scheduling or cost questions happen.
• Given orally when scheduling or when someone asks about the cost of items or services.
• Made available in accessible formats and in the languages spoken by the people considering or scheduling care with you.

In practice, that means a real page on your site, not a line buried in a PDF. A short page titled something like Good faith estimates for self-pay patients, linked from your pricing page, your booking page and your footer, is easy for patients and search engines to find. Your practice website should treat it as a standard page, like your privacy policy.

The rule also says any discussion or inquiry about the potential cost of items or services must be treated as a request for a good faith estimate. A patient who asks the front desk or a chat assistant what a treatment costs has, in the rule’s terms, asked for an estimate.

Timelines your front desk needs to know

CMS lays out the timing for patients:

• Care scheduled 0 to 2 business days ahead: the patient is not entitled to a good faith estimate.
• Care scheduled 3 to 9 business days ahead: the estimate is due within 1 business day of scheduling.
• Care scheduled 10 or more business days ahead: the estimate is due within 3 business days of scheduling.
• A patient who asks before scheduling: the estimate is due within 3 business days of the request.

Estimates must be in writing, on paper or electronically as the patient asks, and the regulation treats an issued estimate as part of the patient’s medical record. If the scope changes, for example a different provider or added services, the convening provider must issue a new estimate.

What an estimate must include

Section 149.610(c) lists the content. Among other items, the estimate must include:

1. Patient and date details. The patient’s name and date of birth, and the scheduled date if one is set.
2. A description of the main service. In clear and understandable language.
3. Itemized expected charges. Items or services reasonably expected for the period of care, with applicable diagnosis codes, expected service codes and expected charges for each.
4. Provider details. Names, National Provider Identifiers and Tax Identification Numbers of each provider or facility represented, and the state and office or facility locations.
5. Separately scheduled care. A list of related items or services expected to be scheduled separately, with a disclaimer that separate estimates will be given on request.
6. Required disclaimers. That there may be additional recommended items or services not reflected, that it is only an estimate and actual charges may differ, that the patient has a right to dispute resolution if billed charges are substantially in excess of the estimate, and that the estimate is not a contract and does not require the patient to get care from the listed providers.

For recurring services, such as a series of visits, the rule allows a single estimate if it states the expected scope (timeframes, frequency and total number) and does not exceed 12 months.

The 400 dollar dispute threshold

Under 45 CFR 149.620, a self-pay patient can start the patient-provider dispute resolution process if the total billed charges from a provider or facility are substantially in excess of the estimate, which the rule defines as at least 400 dollars more than the expected charges listed for that provider or facility. CMS also tells patients they need a good faith estimate to dispute a bill, and that they can submit a complaint if they did not get one when they should have.

The practical lesson is to build realistic estimates. An estimate that leaves out an expected add-on to make the number look smaller creates the gap that leads to disputes.

The rule also lets a patient’s authorized representative start the dispute process, with exclusions for the providers in the estimate and people tied to them. Patients who hire outside help with bills and disputes are working with businesses that have their own rules on savings claims and fees, covered in our guide to patient advocate marketing.

Price marketing and estimates should agree

Many self-pay practices advertise prices: a new patient exam special, a per-unit price, a membership fee, a package. The good faith estimate rule does not ban that, but it raises the stakes on accuracy, because the patient will later receive a written estimate and, possibly, a bill to compare it with.

• Make sure the price on an ad or landing page matches what the estimate will show for the same service, or say plainly what the advertised price covers.
• If an advertised price depends on conditions (a first visit, a package, a specific area treated), state the conditions next to the price.
• Do not advertise a price that leaves out items your estimates normally include, such as a consultation fee or required follow-up.
• Train anyone who answers price questions, including staff and any phone or chat assistant, to treat a cost question as an estimate request and route it to the person who prepares estimates.

Our guides to healthcare landing pages and advertising patient financing cover the wider rules on price and offer wording.

A short setup checklist

1. Publish the notice page. Clear, searchable and linked from pricing, booking and the footer, in the languages your patients speak.
2. Post the notice in the office. Where scheduling and cost questions happen.
3. Update scheduling scripts. Ask about insurance status, mention estimates out loud, and log requests. Our new patient phone script is a starting point.
4. Build an estimate template. With every element in 149.610(c) and the required disclaimers.
5. Set a timer. Track the 1 and 3 business day deadlines.
6. Store issued estimates. With the patient’s record, and provide copies on request.
7. Review prices together. Each time you change advertised prices, update estimate templates, and the other way around.

Patients with Medicare who see an opted-out clinician raise a separate estimate question, covered in our guide to Medicare opt-out practice advertising.

When a bill goes unpaid, the rules on statements, billing texts, collection agencies and credit reporting are in our medical debt collection rules guide.

The price on your website is a separate duty from the estimate. See our guide to state all-in pricing laws for practices for advertised prices and mandatory fees.

Sources

• 45 CFR 149.610: Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals
• 45 CFR 149.620: Requirements for the patient-provider dispute resolution process
• CMS: What is a good faith health insurance estimate?

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