Answers / Good faith estimates
Good faith estimate requirements under the No Surprises Act
Uninsured and self-pay patients must receive a written good faith estimate of expected charges. Care scheduled at least 10 business days ahead requires the estimate within 3 business days of scheduling; care scheduled 3 to 9 business days ahead requires it within 1 business day; and a request requires one within 3 business days. If the final bill exceeds the estimate by $400 or more, the patient can dispute it.
Who gets an estimate
The No Surprises Act requires good faith estimates for uninsured patients and for insured patients who are not using their coverage, the self-pay cases. Anyone shopping for care can also request an estimate before scheduling anything. The companion provision for insured patients, advanced explanations of benefits delivered through their plan, remains deferred pending rulemaking, so the live compliance obligation runs to uninsured and self-pay patients.
The deadlines
| Situation | Estimate due |
|---|---|
| Care scheduled at least 10 business days ahead | Within 3 business days of scheduling |
| Care scheduled 3 to 9 business days ahead | Within 1 business day of scheduling |
| Patient requests an estimate | Within 3 business days of the request |
Care scheduled less than 3 business days out does not require an estimate; there is no time to produce one.
What the estimate must contain
The estimate must be written, itemized, and specific: the patient's identifying information, a description of the primary item or service, the expected items and services grouped with their service codes and expected charges, the providers and facilities expected to furnish them, and the required disclaimers, including that the estimate is not a contract and that the patient-provider dispute process exists. Verbal ballparks do not count, and the estimate becomes part of the patient's record.
The $400 threshold
The estimate has teeth. If the billed charges come in at least $400 above the good faith estimate, the patient can take the bill to the federal patient-provider dispute resolution process, where an independent reviewer decides what is owed, anchored to the estimate. For a practice, a pattern of blown estimates means fee exposure, refunds, and administrative time. The clean fix is boring: template the common service bundles, code them once, and regenerate when the plan of care changes.
Where groups slip
Three recurring misses. Scheduling staff who treat the estimate as optional paperwork rather than a statutory deadline. Estimates that cover the primary service but omit the anesthesia, pathology, and facility components that belong on the same estimate when furnished by co-providers. And no process for reissuing when the plan of care changes, which leaves the old number as the one the $400 test runs against.
Compliance is half the law
The other half pays you: underpaid protected claims go to federal arbitration, where providers win 85.8 percent of decisions. Lido IDR files them for a flat fee per arbitration. Talk to an IDR specialist.