Providers: payment resolution with patients
Providers: what to expect when a patient starts payment dispute resolution
The “No Surprises” requirements are effective as of January 1, 2022, and protect uninsured (or self-pay) consumers from many unexpected high medical bills. If a consumer doesn’t have health insurance, or doesn’t plan to use that insurance to pay for health care items or services, they must be given a “good faith estimate” of what they may be charged, before they get the item or service. Once an uninsured (or self-pay) consumer schedules an item or service (like a medical device, a doctor’s visit or a surgical procedure) with a health care provider or health care facility, that provider or facility must give them a good faith estimate of the amount it expects to charge for that item or service. A provider or facility must also give this good faith estimate when a consumer requests it (regardless of if they schedule the item or service).
A patient-provider dispute resolution process is now available for uninsured (or self-pay) consumers who get a bill from a provider that’s at least $400 more than the expected charges on the good faith estimate. Under the patient-provider dispute resolution process, an uninsured (or self-pay) consumer, or their authorized representative, may initiate the dispute process. This process brings in an independent third-party called a dispute resolution entity to determine the appropriate amount the consumer must pay.
If a consumer chooses to dispute a charge for an item or service, the provider will be asked to provide:
- The good faith estimate they provided their patient.
- The bill they sent to their patient.
- Any supporting documents that help to explain why the bill is higher than the estimate.
Providers will be emailed a link to the federal dispute resolution portal where they can upload the requested documents. The dispute resolution entity will contact the provider if any additional information is needed. Once a determination is made, the dispute resolution entity will notify the provider and the patient.
During the patient-provider dispute resolution process, the provider and patient can continue to negotiate the bill. During this process, providers:
- May not move the bill into collections or threaten to do so.
- Must pause collections if the bill is already in collections.
- Can’t collect late fees on unpaid amounts.
- Can’t threaten to take any retaliatory action against the patient for initiating the patient‑provider dispute resolution process.
If the provider and patient agree on a payment amount before the dispute resolution entity makes a determination, the provider must notify the dispute resolution entity as soon as possible, but no later than 3 days after the settlement. Providers should complete this notice of payment settlement (PDF) (en Español) (PDF), and send it and any supporting documents by encrypted email to FederalPPDRQuestions@cms.hhs.gov.