No Surprises Act for Providers: Good Faith Estimates

Providers' offers were selected in 85% of payment determinations in 2024, according to the CMS federal IDR supplemental background report for 2024. That figure doesn't mean filing more cases is the strategy. It means the No Surprises Act now rewards practices that screen claims correctly, meet every notice deadline, support a defensible offer, and reconcile the money after a decision. A favorable determination that never becomes reconciled cash isn't a win. It's unfinished revenue work. No Surprises Act Coverage at a Glance The No Surprises Act protects patients from surprise out-of-network bills in specific care settings and gives providers a federal dispute path when that protection applies and payment stays unresolved. Map every payer and service line to one row below before you build workflows around any single rule. No Surprises Act Protections by Situation Situation Protection Route When Unresolved Emergency services out of network Patient cost-sharing limited to in-network levels; no balance billing Open negotiation, then federal IDR Non-emergency services at an in-network facility Out-of-network billing limited unless the patient gives valid consent Open negotiation, then federal IDR Air-ambulance services Out-of-network billing limited for covered air-ambulance transport Open negotiation, then federal IDR Uninsured or self-pay patients Good Faith Estimate required before the service Patient-provider dispute resolution The law established federal protections against unexpected out-of-network bills for emergency services, certain non-emergency services provided at in-network facilities, and air-ambulance services, and its principal consumer-protection provisions took effect on January 1, 2022, while the federal Independent Dispute Resolution process became operational in April 2022, as summarized in the Congressional Research Service report on the No Surprises Act. In that same report, parties initiated more than 1.46 million federal IDR disputes in 2024, over twice the 679,156 disputes initiated in 2023, and approximately 1.42 million, or 97%, involved out-of-network emergency or non-emergency services. That scale changes how you should staff this work. IDR isn't a patient-billing footnote handled when someone has spare time. It's a high-volume reimbursement channel that affects provider revenue, documentation quality, coding, payer follow-up, and claims strategy. Practices lose money when they treat all out-of-network claims as identical. Emergency care, facility-based non-emergency care, air transport, and self-pay estimates follow different triggers and different dispute routes. A claim placed in the wrong row can miss its notice window or enter a process where it doesn't belong. Start with a simple inventory. For each service line, record the facility relationship, network status, payer mix, typical remittance pattern, and who owns the next deadline. Then compare that inventory against the current No Surprises Act regulations and implementation requirements so gaps show up as operational tasks, not surprises after a denial.

Map the claim before you chase the payment. The row it belongs in determines the notice, the deadline, and the dispute route.

What a Good Faith Estimate Must Include A Good Faith Estimate has to let a patient identify the planned care, understand the expected charges, and know what to do if the final bill is materially higher. Accuracy alone isn't enough. A clear estimate that's missing a required element still creates exposure because that document becomes the reference point for a later patient dispute. Required Elements in Order Patient identifying information and issue date: Match the estimate to the person receiving care and record the exact date you issued it. Don't rely on a print date buried in a portal record. Each scheduled item or service by code: List every scheduled item or service with its CPT or HCPCS code. A friendly generic description is helpful for the patient, but it can't replace the code. Supporting diagnosis codes: Connect each item or service to the diagnosis that supports it. A missing diagnosis makes it harder to explain why a service belongs in the estimate. Expected charge and furnishing provider: Show the expected charge for each item, plus the name and NPI of the provider or facility that'll furnish it. Omitting the facility NPI is a common error when part of the care happens at a facility. Patient rights notice: State that the estimate isn't a contract, that the patient may choose to use insurance, and that the patient may dispute a bill that exceeds the estimate by $400 or more. Contact information: Give the patient a working route for questions about the estimate. A generic front-desk number that nobody monitors for estimate questions doesn't solve the problem. Watch for mismatches between scheduling, clinical documentation, and the estimate. If the scheduled service changes but the dollar amount doesn't, or the code describes a different service than the appointment type, staff should stop and correct the document before sending it. Plain language matters alongside the codes. For an example of how a practice can present expected charges clearly to families before care begins, review the estimated costs of teen counseling from Katy Teen & Family Counseling. The lesson isn't to copy another specialty's prices. It's to make the estimate readable enough that the patient doesn't need billing training to check it. Use a final tick test. A billing manager should be able to check every element against the document before it's sent, using a template reviewed each quarter for stale codes, old NPIs, changed locations, and outdated contact routes. When a Good Faith Estimate Is Due A patient scheduled for self-pay care gets a Good Faith Estimate, and the clock starts the moment the appointment hits the schedule. That rule applies to uninsured or self-pay patients and to patients who choose not to use insurance for a scheduled service. Status must be confirmed at scheduling, not discovered at check-in. If staff assume a patient will use coverage and the patient later chooses self-pay, you've already lost part of the delivery window. Good Faith Estimate Delivery Deadlines Scheduling lead time Deadline to send Notes Scheduled 10 or more business days ahead Within 3 business days of scheduling Standard window for planned care Scheduled 3 to 9 business days ahead Within 1 business day of scheduling Send at booking to stay inside the window Scheduled fewer than 3 business days ahead No federal timing deadline applies The timing rule does not reach this window; document the scheduling date and the reason no estimate was required I would make scheduling staff own the first calculation, with billing verifying it the same day. That split works because scheduling knows when the appointment was created, while billing can confirm the estimate contains the right codes and charges before delivery. The third row trips up front desks most often. Short-notice bookings still need a documented scheduling date and a note explaining why the timing rule did not apply, because an auditor will ask for the file either way. A Repeatable Delivery Routine Confirm payer status at scheduling: Ask directly whether the patient is uninsured, self-pay, or choosing not to use insurance for this service. Record the scheduling date: Count the business days between scheduling and the appointment in the patient account, not on a sticky note. Select the deadline from the table: Use the lead time to set the due date and assign it to a named staff member. Send it in writing: Deliver the estimate through the patient portal or by mail and use a method you can verify later. Keep proof of delivery: Store the timestamp and delivery record with the estimate in the patient account. Verbal estimates carry no compliance weight. A scheduler may quote a number accurately on the phone, but if you can't produce the written document, its issue date, and proof it was sent in time, you can't show what the patient received. When scheduled care changes significantly, issue a new estimate. Added services, a different furnishing provider, or a materially different expected charge shouldn't ride on an outdated document. The dispute threshold demands the same discipline on the back end. If the final bill exceeds the estimate by $400 or more, the patient can start patient-provider dispute resolution within 120 calendar days of the bill. Keeping the estimate, timestamp, and final bill together means you can show exactly which charges the estimate covered when a dispute lands. That file discipline also helps you apply consistent rules for charging self-pay patients fairly and transparently across locations. Every scheduled service should have a timestamped estimate sent inside its window, or a note explaining why no window applied. If you can't audit that in minutes, your process depends too heavily on memory. How the IDR Process Runs From Negotiation to Decision Federal Independent Dispute Resolution, or IDR, is a time-limited escalation path for eligible out-of-network payment disputes. Each party submits one payment offer, and the certified IDR entity selects one offer rather than constructing a compromise amount. A filed case, or even a favorable ruling, only counts as recovered revenue once the payment posts and reconciles to the determination. The sequence begins when a health plan issues an initial payment or denial. The parties then complete a 30-business-day open-negotiation period, and if unresolved, either party may initiate federal IDR, after which the certified IDR entity must select one offer and payment is due within 30 calendar days of the binding decision, according to the CMS overview of engaging in Independent Dispute Resolution. IDR Deadlines From Initial Payment to Payment Stage Timing Who Acts Open negotiation 30 business days after the initial payment or denial Provider and health plan Initiate federal IDR Within 4 business days after negotiation ends Either party Offer submission By the deadline set after certified IDR entity selection Each party submits one offer with evidence Payment after determination 30 calendar days from the decision Health plan The baseball-style structure changes how you prepare. You choose a final number your evidence can carry, because an unsupported high offer can lose to a lower but better documented payer offer. Submitting your billed charge and hoping the entity lands somewhere reasonable is how recoverable disputes die. Preparing a Defensible Offer Preserve the starting record: Keep the remittance or denial notice with its date, then calculate the negotiation and filing deadlines from that document. Build the evidence around the service: Address service complexity, provider-specific factors, case acuity, teaching status, market conditions, and prior contracted rates where permitted. Keep an auditable event log: Track eligibility, coding, negotiation, initiation, offer submission, determination, and payment reconciliation in one chronology. Separate facts from advocacy: Tie each assertion about acuity or complexity to documentation the entity can inspect quickly. RevGuard manages the full IDR arbitration lifecycle under the No Surprises Act, which reflects the operational point here. Filing is only one stage in a longer chain that starts with claim quality and ends with collected payment. Practices managing the work internally need the same lifecycle view, even if they use simpler tools. Use the event log to assign every date to a named owner before negotiation begins. Staff can keep the sequence straight with a claim-level calendar built from the deadlines in the table above.

Calendar rule: Calculate the negotiation end date, the IDR initiation window, and the payment due date on the day the initial payment or denial arrives.

A missed deadline or an unsupported offer can convert a recoverable underpayment into an administrative loss. Careful preparation takes staff time, but rushed preparation wastes the entire dispute. And a favorable determination that never reconciles to posted payment is a loss in everything but name, so the calendar should stay open until the remittance confirms what the entity awarded. Screening Claims for IDR Eligibility Before Filing Eligibility screening decides whether arbitration can ever become collected payment. A filed case is only an expense until the award is reconciled and paid, so the first question is simple: does this claim belong in federal IDR at all. Ineligible filings consume staff time, pull attention from recoverable claims, and can add fees with no realistic path to payment. I would screen at remittance review, while the codes, notice dates, and payer relationship are still in front of the biller. Waiting until a file is “ready for arbitration” usually means someone has to rebuild facts that were visible on day one. Screening Sequence Pull the remittance first: Record every claim adjustment and remittance code, then read those codes against the actual service, setting, and payer relationship. Confirm the eligible category: Determine whether the service is emergency care, non-emergency care at an in-network facility, or air-ambulance transport. Inspect complicating claim features: Check whether multiple modifiers, bundled services, or facility relationships change how the service should be treated. Verify open negotiation: Confirm the notice was sent inside the required negotiation window and keep proof with the claim. Determine jurisdiction: Decide whether state or federal jurisdiction applies before selecting a filing route. Model net recovery: Run the qualifying payment amount comparison, then weigh the expected award against filing fees and likely recovery. In Phase 4, RevGuard models IDR viability by comparing expected award against QPA distortion, filing fees against net recovery, and reviewing payer arbitration history. An eligible claim can still be a weak filing when the likely award leaves too little after fees, labor, and follow-up.

Stop claims that fail the category, jurisdiction, or negotiation checks. Do not spend arbitration money to learn what a remittance review could have told you.

Specialty practices need payer-specific interpretation because the same code pattern can point to different next steps depending on plan type, facility relationship, and service setting. Keep eligibility decisions with billing staff; routine status calls can sit with insurance customer communication support so payer and patient contact does not crowd the screening file. Make the stop rule explicit. Close a claim when it fails category, jurisdiction, or negotiation checks, or when expected net recovery is too small to justify proceeding. Record the reason in plain language so another staff member does not reopen it without new evidence. Clean upstream work protects the downstream result. Accurate coding, correct modifiers, timely notices, and clear proof of service eligibility give the payment argument credibility before an offer is ever drafted. From an IDR Win to Reconciled Payment Say a practice bills $4,000 for an out-of-network emergency procedure and the plan initially pays $1,200. The practice offers $3,100 in IDR, the plan offers $1,500, and the IDR entity selects the practice's $3,100 offer. On day 30 after the decision, the plan sends another $1,200 payment, leaving a $1,900 shortfall against the awarded amount. That practice shouldn't record a win and move on. It should escalate the same day with the determination, the remittance, and a simple calculation showing the awarded amount, amount received, and balance still due. Waiting for the next monthly accounts receivable review gives a late or incomplete payment time to age into a harder collection problem. Reconciliation Steps After a Determination File the determination: Store the decision with its date and awarded amount in the claim record. Calendar the payment deadline: Enter the 30-calendar-day due date on the day the decision arrives. Reconcile against the award: Compare each remittance line with the awarded amount, not the original billed charge or initial payment. Escalate with evidence attached: Send the determination, remittance, and shortfall calculation when payment is late or incomplete. Classify the remaining problem: Separate a payment delay from a new underpayment, because a new underpayment starts a different dispute analysis. Post-determination payment is a real compliance risk. The CMS December 2025 complaint data and enforcement report recorded 39,999 complaints from 2022 through 2025, identified late payment after 30 days from an IDR determination as a complaint category, and reported approximately $30.1 million in direct monetary relief to consumers and providers from CMS investigations. We track payer-specific tactics, arbitration outcomes, and compliance behavior to inform IDR strategy because payers don't all behave the same way after losing. One plan may pay correctly with a reminder. Another may short-pay repeatedly unless every award is reconciled line by line. The planned federal IDR Gateway may improve case visibility, but it won't replace your internal post-award controls. Your system still has to know what's due, what arrived, what's missing, and who escalated it. Measure IDR by realized, reconciled payment, not cases filed or favorable determinations alone. A dashboard that celebrates decisions while cash sits unpaid gives leadership the wrong number and gives payers no reason to change. Confirm Your Notice and IDR Workflow This Quarter Give this work named owners. Assign one person to Good Faith Estimate delivery and another to IDR deadlines, with a backup for each role. Shared responsibility without a named owner usually means nobody notices a missed date until recovery is already compromised. Put every open-negotiation start date, IDR filing deadline, and 30-calendar-day payment date into one shared calendar. Review it weekly for items due in the next 14 days and monthly for late post-award payments. If a date lives only in one employee's inbox, it's not controlled. Place the eligibility screen where remittances are reviewed. Each claim should leave that review with one of three decisions: negotiate, prepare for IDR, or close. Set a maximum time for that decision so underpayments don't drift while staff debate whether they're worth pursuing. Keep the event log from eligibility and coding through negotiation, filing, determination, and reconciliation. Then run a quarterly template check. Compare every Good Faith Estimate template against the required elements, confirm NPIs and contact routes, and remove obsolete versions from shared drives and portal libraries. RevGuard is a medical billing and revenue cycle management firm that specializes in No Surprises Act IDR recovery, and practices that want outside help can compare it against other options after completing their own internal review. RevGuard also offers four downloadable resources: "IDR Without Upfront Fees: A Provider Guide", "Out-of-Network Revenue Recovery Playbook", "RCM Readiness Checklist for NSA & IDR", and "Payor Tactics in IDR". A practice with clean notices, accurate eligibility screening, defensible offers, and a payment reconciliation routine has the best chance of turning favorable decisions into cash. That's the standard to build toward this quarter. If your team is filing IDR cases but can't quickly show which awards were paid in full, which were short-paid, and which claims should never have been filed, start with a workflow review. RevGuard helps provider organizations connect eligibility screening, evidence preparation, IDR filing, enforcement, and payment reconciliation so favorable decisions become collected revenue.