Does a chiropractic clinic owe a good faith estimate to a self pay new patient?

Yes, when a new patient is uninsured or chooses not to use insurance and books a visit at least 3 business days ahead, the clinic owes a written good faith estimate within 1 or 3 business days of booking, or within 3 business days of a request. GoHighLevel can flag the patient, start the clock, and create the task that keeps the clinic on time. The bottom line: this is a federal deadline that applies to every licensed provider, and a missed deadline is easier to prevent with a date and a task than with memory.

What the rule says

The CMS overview of the No Surprises Act says that beginning January 1, 2022, licensed or certified health care providers and facilities must give uninsured or self pay individuals a written estimate of expected charges, called a good faith estimate, upon scheduling or on request, and that the provisions discussed apply only to uninsured and self pay individuals. CMS describes self pay as including insured patients who choose not to submit a claim to their plan. The estimate must be provided no later than 1 business day after scheduling if the service is scheduled at least 3 business days in advance, and no later than 3 business days after scheduling if the service is scheduled at least 10 business days in advance. When a patient asks for an estimate, it is due within 3 business days of the request. No estimate is required if the service is scheduled fewer than 3 business days ahead, and if the expected scope changes, a new estimate is due at least 1 business day before the service. Burr and Forman adds that any inquiry by an uninsured or self pay patient about potential costs should be treated as a request. A consumer guide says patients can dispute the bill if the final charges exceed the estimate by $400 or more.

The three clocks

What the estimate includes

According to CMS, the estimate must include expected charges for the main service and for items and services reasonably expected to be furnished with it, such as an exam, X rays, and adjustments in a first visit. Think of it as the first visit plus the services the doctor expects to add. The care plan that follows is a separate conversation, but if the patient also asks what a 12 visit plan costs, the question is an inquiry that should be answered in writing.

Build it in HighLevel

1. Add contact fields Insurance type, Booking date, and Appointment date, and keep Self pay as a value.
2. Start a workflow when a new patient appointment is booked. Use an If/Else on Insurance type is Self pay, or the patient said they will not use insurance.
3. Calculate the business days between booking and the appointment in your system and enter the result in a field called Business days ahead. HighLevel does not know your holiday calendar.
4. Branch on Business days ahead: 3 to 9 creates a front desk task due the next business day, and 10 or more creates a task due in 3 business days. Fewer than 3 creates a courtesy task.
5. Create the same task when a patient submits a form or message that contains a cost question, tagged as Estimate request.
6. After the estimate is sent, add the tag Estimate sent with the date, and add a task to send a new one at least 1 business day before the visit if the plan changes.
7. Review open estimate tasks every morning.

A message, written out

Sample: Hi Chris, this is [Clinic]. Thank you for booking your first visit on Friday. We have emailed your written good faith estimate of the expected charges for your visit. Please review it, and call us at [number] if you have questions. Reply STOP to stop messages. The estimate itself goes by email or your secure portal, not in the text.

Worked example

A clinic that books 30 new patients a month, with 40 percent self pay, sends 12 estimates a month (30 times 0.4). If 3 of those are booked fewer than 3 business days ahead, 9 are subject to the 1 or 3 business day clock. Each of the 9 shows up as a dated task, so none depends on someone's memory. The 40 percent and the 3 are assumptions, so replace them with your own mix.

Posting and telling patients

CMS's toolkit lists telling uninsured and self pay individuals about their right to an estimate among provider responsibilities. Put the notice on your website, in your reception area, and in your new patient confirmation, and ask your counsel or billing partner how to word it. This article describes the timing rule, not your full obligations.

Practical points for the front desk

CMS provides a standard form for the good faith estimate, so use it or a version that includes the same information, and keep a copy in the patient's file with the date it was sent. Send it by the method the patient prefers, and record that method. If a patient asks about the price of a visit in a phone call, treat the call as a request, write down the date, and put the three business day deadline on the task list the same day.

If the final bill is higher

A consumer guide says patients can start a federal dispute process if the final charge exceeds the estimate by $400 or more. The best protection is an estimate that anticipates the services the doctor expects to add, such as X rays at the first visit. If the doctor's plan changes before the visit, send a new estimate at least 1 business day ahead and keep it with the first one.

How this was handled before

Cash pay patients got a verbal price at the desk, or a fee sheet in the new patient packet. A written, itemized estimate on a deadline is new, and the clinics that do it well build the deadline into the workflow.

What to measure

Track self pay bookings, estimates sent within the deadline, late estimates, and estimate requests that arrived by phone or message. The late estimate count should be zero.

Questions people ask

When must a clinic give a good faith estimate?

Within 1 business day of scheduling if the service is booked 3 to 9 business days ahead, within 3 business days if booked 10 or more business days ahead, and within 3 business days of a request.

Who is a self pay patient?

An uninsured patient, or an insured patient who chooses not to use insurance, according to CMS.

What if the estimate changes?

A new estimate is due at least 1 business day before the service if the expected scope changes.

To build the estimate tracker, start a GoHighLevel account here. Workflows and tasks appear together in our capabilities demo.