Cost Estimates

If you do not have health insurance, or if you do not plan to use your insurance to pay for a medical item or service, you are considered to be an “uninsured” or “self-pay” patient. In this situation, before you receive the medical item or service, a health care provider or facility (such as Agrace) must give you a “good faith” cost estimate, with details of how much you may be charged.

The good faith estimate will include these items:

• A list of items and services that the scheduling health care provider or facility reasonably expects to provide you for that period of care.
• A list of items and services—and their costs—that can be reasonably expected to be given to you by another provider or facility that is involved in your care (a co-provider or co-facility).
• Applicable diagnosis codes and service codes (these affect how your item or service is billed).
• The expected charges or costs for each item or service from each provider and facility.
• A notice that if the billed charges are higher than the good faith estimate, you can:
  – ask your provider or facility to update the bill to match the good faith estimate,
  – ask to negotiate the bill (discuss a lower amount), or
  – ask if financial assistance is available.

Steps for Disputing a Bill that is $400 or More than Expected

The good faith estimate will also tell you how to dispute (reject) your bill, while the amount is investigated. If you get a bill that is at least $400 more for any provider or facility than the total expected charges shown for that provider or facility on the good faith estimate, you can use a patient-provider dispute resolution (PPDR) process. It’s through the U.S. Department of Health and Human Services (HHS).

To start the patient-provider dispute resolution process, call (800) 985-3059 or go to cms.gov/nosurprises/consumers. Note: If you follow the link to this CMS web page, there is an option to display the information in Spanish. 

Please note:

• You must start the dispute process within 120 calendar days (about four months) of the date on the original bill.
• There is a $25 fee to use the dispute process.
• You may request a payment review and decision from an independent company certified by HHS.

Agrace cannot take or threaten to take any punitive (punishing) action against you for disputing your bill.

Here are more details about the Department of Health and Human Services patient-provider dispute resolution process.

Questions about good faith estimates may be directed to Jennifer Flugaur, Agrace’s chief quality officer: (608) 327-7291 or jennifer.flugaur@agrace.org