January 21, 2022
CMS, Office of Strategic Operations and Regulatory Affairs,
Division of Regulations Development,
Attention: Document Identifier/OMB Control Number: CMS-10791
Room C4–26–05,
7500 Security Boulevard,
Baltimore, Maryland 21244–1850
Submitted online via www.regulations.gov

Re: CMS–10791 Requirements Related to Surprise Billing; Part II Proposed Collection with
Request for Comments (OMB control number: 0938– NEW)
Dear Sir/Madam:

On behalf of the American Association of Oral and Maxillofacial Surgeons (AAOMS), which
represents more than 9,000 oral and maxillofacial surgeons (OMSs) in the United States, thankyou for the opportunity to comment on the Proposed Collection of Information related to“Requirements Related to Surprise Billing; Part II,” as published in the Federal Register onJanuary 5, 2022.

OMSs – many of whom are part of small practices – are also an integral part of hospital systems,
providing emergency department coverage, serving as essential members of trauma teams
throughout the country and performing complex procedures at hospitals. AAOMS supports
efforts to prevent patients from being unfairly surprised by an out-of-network bill, while
ensuring that providers have the opportunity to be reimbursed at a fair and reasonable rate.

AAOMS remains committed to consumer protection and education, ensuring patients have thetools and resources available to understand the costs of care. We understand that the provisionof Good Faith Estimates (GFE) for scheduled or requested services is an integral component of
the patient protections against surprise medical bills set forth under the No Surprises Act(NSA); however, AAOMS is concerned that certain requirements outlined in the Interim FinalRule (IFR), specific to the provision of GFEs, the interpretation of a “health care facility,” andthe patient-provider dispute resolution process for uninsured (or self-pay) individuals, pose
great challenges for and represent undue administrative burden to providers, especially thosein small group practices.

The provision of GFEs for uninsured (or self-pay) patients presents unique challenges foroffice-based providers.

First, we would like to thank CMS for delaying the implementation of the provision of GFEs for
insured patients beyond January 1, 2022, recognizing the significant administrative andlogistical challenges this poses for both providers and insurers. Clearly, it will take time for all
relevant stakeholders to come together to create meaningful pathways and protocols to allow
for seamless integration of patient care and insurance reimbursement.

Arguably, for those providers who routinely provide services in ambulatory surgical centers(ASCs), hospital outpatient facilities or inpatient hospitals, processes may already exist togenerate and communicate treatment costs to uninsured (or self-pay) patients. On the otherhand, most OMSs are primarily office-based, functioning within the constraints of smaller
practices. These OMSs face unique challenges in providing a GFE for patients being treatedoutside of the office setting, particularly with respect to the requirement that providers include
items and services of co-providers/co-facilities involved in the patient’s care.
In the case of nonemergency surgical services, the OMS is often subject to the schedulingconstraints and the limited availability of specialty-specific equipment and supplies in facilities
in which they have privileges. As such, it is uncommon for ancillary providers (e.g.,
anesthesiologists, radiologists or hospitalists) associated with an OMS procedure to have theirrespective procedures predetermined at the time of scheduling.

Similarly, the insurance and network information for ancillary providers are often notcommunicated to the OMS in advance of the procedure nor are the procedures predetermined.
As a result, procedures are often performed prior to predetermination of insurance coverage.

In addition to questions surrounding the accuracy of GFEs in such instances, office-based
practices also are not likely staffed to adequately accommodate the increased communicationthat will be required between facilities and co-providers for the provision of GFEs to uninsured(or self-pay) patients within the restrictive timeframes being implemented.
Also, it is our understanding that GFEs must be provided for scheduled as well as requested
services. While AAOMS appreciates the importance of transparency in the cost of health careservices, the provision of a GFE in cases in which the provider does not already have an
established relationship with the individual requesting it - presumably for purposes of pricecomparison - places additional burden on the OMS practice and once again calls into question
the accuracy with which such an estimate is able to be provided.

AAOMS recognizes the fact that the Department of Health and Human Services (HHS) is
cognizant of these considerable challenges and supports the decision to exercise enforcement
discretion through December 31, 2022.

A “health care facility” must not include the office-based setting

AAOMS also seeks clarification as to the scope of the requirements for the provision of GFEs,
specifically with respect to the “providers” and “facilities” to which the provision pertains. It

has been the general understanding - and a point that AAOMS has previously requested
clarification on - that the definition of “health care facility,” as outlined in the IFR, does notinclude physician and/or dental office-based settings.

Yet, in December 2021, CMS released a set of Frequently Asked Questions regarding GFEs foruninsured (or self-pay) individuals, prepared by HHS, which maintains that the requirement toprovide a GFE for scheduled or requested services pertains to providers of all specialties,
facility types and sites of service. The implications are that office-based providers areresponsible for providing GFEs to uninsured (or self-pay) patients not only for those
procedures performed in ASCs, hospital outpatient facilities or inpatient hospitals, but also for
those performed in an office setting, allowing for somewhat ambiguous interpretation of theGFE requirements.
A large percentage of OMS procedures are safely and routinely performed in the office setting.
However, site of service differentials between large health care organizations and small grouppractices includes both economies of scale and staffing limitations. With such constraints as
high-volume demand, staff size and quick turnaround times, the provision of GFEs foruninsured (or self-pay) patients for office-based services will be difficult at best.

In summary, small office-based practices generally lack the robust administrative frameworknecessary to comply with the requirements already in effect regarding the provision of GFEs
for uninsured (or self-pay) patients. For physician and dental offices still attempting tonavigate the continually evolving health care landscape, such provisions place additional
administrative burden on an already strained system. OMS offices battling staffing shortages,
physician burnout and steadily decreasing resources are ill-equipped to design and implement
novel workflows while striving to maintain clinical best practices and optimal patient
outcomes.
The definition of “substantially in excess” will be problematic.

An integral part of the Patient-Provider Dispute Resolution Process, the IFR states that bothproviders and facilities are required to submit information to select dispute resolution (SDR)
entities to allow for informed payment determinations to be made in the event billed charges
are deemed “substantially in excess” of the corresponding GFE.
Although the process has implications of furthering the administrative burdens alreadyinherent to the implementation of the NSA, AAOMS supports a standardized and consistentdispute resolution process and agrees that such a process is necessary to ensure increasedtransparency and prevent surprise medical bills.

From a clinical standpoint, even a straightforward procedure may exceed the base threshold of$400. Thus, absent a more appropriate threshold amount at which the dispute process may beinitiated, this could lead to the routine over-estimation of charges as a way of avoiding thepatient-provider dispute resolution process in its entirety. Such practices could have thereverse effect on the perceived cost of care, limiting accessibility and ultimately delaying
patient care.

As such, AAOMS strongly encourages HHS to reconsider what is defined as “substantially inexcess” of the good faith estimate.

Thank you for your consideration of these comments. Please contact Patricia Serpico, AAOMS
Director of Health Policy, Quality & Reimbursement, with any questions at 800-822-6637, ext.
4394 or pserpico@aaoms.org.
Sincerely,

J. David Johnson Jr., DDSAAOMS President