Download Support Tools
Download, review and save these important tools to assist with financial considerations in your practice. Self-pay patients are no longer the easiest patients in the clinic. Because of regulations such as the No Surprises Act, providers must acknowledge these patients at the time their appointment is made and offer them the choice to receive a Good Faith Estimate for the recommended services. This support tool will aid the clinic in identifying patient types that should be offered an estimate. Please keep in mind, the Good Faith Estimate is just a small part of this very complex rule. Be sure to check out KMC University’s more comprehensive training on the No Surprises Act along with all the tools you need to be compliant.
The customizable Acknowledgement to Self-Pay for Non-Covered Services support tool is intended for use when patients receive a service or procedure that is considered non-covered by their insurance and the patient is utilizing insurance for other services in the clinic. Locate the payer’s Advance Member Notice form, if any, before defaulting to the KMC University form. Payers often have their own forms. There may be specific services listed in the payer policy that cannot be included in an advance notice acknowledgment form (such as capitated services or bundled procedures). It is important to note that if patients are self-pay (not utilizing their insurance) and you are not filing a claim with their insurance, you need to follow the rules of the Good Faith Estimate as outlined by the No Surprises Act. These individuals receive notice of out-of-pocket expenses through that arrangement and specific form.
|Patient Acknowledgement Form for Non-Covered Services
||No Surprises Act (NSA) GFE Decision Making Matrix|