November 4, 2022

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-9900-NC
P.O. Box 8013
Baltimore, MD 21244-8013
Submitted online via www.regulations.gov

Re: File Code CMS-9900-NC Request for Information; Advanced Explanation of Benefits and Good
Faith Estimate for Covered Individuals
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, weappreciate the opportunity to provide information regarding certain price transparency provisionsof the No Surprises Act (NSA), including the provision of good faith estimates (GFEs) for covered
individuals.
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 and other types ofhealthcare facilities.

AAOMS supports efforts to increase cost transparency in the delivery of healthcare services andunderstands the significance of empowering patients to make informed decisions about their care.
We agree that the provision of a GFE for scheduled or requested services- regardless of a patient’s
insurance status- is an integral component of the consumer protections set forth under the NSA.

Our association also appreciates that the Centers for Medicare & Medicaid Services (CMS) has
delayed enforcement of certain provisions, such as GFEs for covered individuals. The costtransparency requirements currently in effect have placed considerable administrative burden on
healthcare providers across all specialties. Therefore, it is crucial the remaining GFE provisions areimplemented in such a way as to mitigate further administrative burden on providers and prevent
unnecessary delays in patient care.

To date, health information technology vendors and standards organizations have made significant
contributions in addressing the technological challenges presented by the provision of GFEs forcovered individuals and advanced Explanation of Benefits (AEOBs). Data standards and operating
rules adopted industry-wide will be essential to facilitate accurate and meaningful healthcare
information exchange. Despite the existence of mechanisms that show potential in meeting datatransfer requirements, the fact remains that the price transparency provisions of the NSA, including
the provision of GFEs for covered individuals, still pose significant operational challenges forhealthcare providers. These challenges include, but are not limited to, structuring new workflows
and establishing communication channels between providers, healthcare facilities and insurance
carriers. AAOMS supports the goal of cost transparency but encourages CMS and other federal
agencies to ensure the appropriate technology infrastructure, such as a Health Insurance
Portability and Accountability Act (HIPAA) administrative standard, for the transmission ofgood faith estimate information from providers to health plans is in place with guidance
prior to implementing remaining cost transparency provisions.
GFEs for covered individuals will place additional administrative burdens on an already strained
healthcare workforce

Through the ongoing public health emergency (PHE), providers and healthcare organizations havecontinually met the challenge to deliver safe, quality and cost-effective care while finding novel
ways to maintain a sound business model. Navigating a return to normalcy has been particularly
difficult for solo or small practices – which describe most oral and maxillofacial surgery practices.
Research by the American Dental Association’s Health Policy Institute shows that dental practiceschedules were, on average, approximately 86 percent full as of September 2022 1. Although this ispositive, staffing shortages remain a significant constraint to expanding patient volume to prepandemic levels; this is compounded by the fact that dental practice expenses have increased
significantly in the past year1.

Industry-wide inflation and staffing shortages have been exacerbated by the need to allocate
increasingly scarce resources to develop the infrastructure and processes necessary to ensurecompliance with NSA requirements, including the provision of GFEs to uninsured or self-payindividuals. Small office-based practices generally lack a robust administrative framework; yet
operationalizing this process has required providers to establish new and often manual workflows
and communication channels. This has placed an undue administrative burden on an alreadystrained healthcare workforce. Indeed, reports throughout the industry have indicated that nonclinical and/or administrative staff are required to devote a considerable amount of work hours tocomplete GFEs for uninsured or self-pay individuals in accordance with the regulation.

Comprehensive GFEs for covered individuals are inherently more complex. Developing accurate
advanced cost estimates for covered individuals and transmitting the requisite information to theirrespective health plans, within the significantly restrictive regulatory timeframes, will undoubtedly
require more administrative staff hours to complete. The nature of this process will require staff

1American Dental Association Health Policy Institute. State of the Dental Economy – Q3 2022 Update.

https://www.ada.org/-/media/project/ada-organization/ada/adaorg/files/resources/research/hpi/state_of_dental_economy_q3_2022_slides.pdf?rev=caa5c08c6ecc4a9298e2
630126a39c3f&hash=FC9E3A38B95C47287D7AA73ECD0B42C7. September 2022. Accessed October 10,2022.

with competencies in coding, billing, revenue cycle management and health information
technology, as well as some clinical knowledge. This may entail hiring more administrative staff orextensive re-training and education of team members reassigned from other criticalresponsibilities, as hiring may not be an option.

Regardless of whether patient case loads reach pre-pandemic levels, GFEs for covered individuals
will apply to a much broader patient population, significantly increasing the burden placed onproviders to meet NSA cost transparency requirements. For instance, according to the 2020 Census,
over 61 percent of Americans are covered under commercial health insurance, whose care would
be subject to GFE and AEOB requirements 2. With such constraints as high-volume demand, staffing
concerns and quick turnaround times, the provision of GFEs for covered individuals for the creationof an AEOB is simply not feasible in the current healthcare landscape, especially for those working
within the limitations of small practice settings. For these reasons, AAOMS urges CMS to adopt a
standard for the provision of GFEs for insured individuals and the creation of advanced EOBs
that would mitigate the administrative burden placed on providers.

Expanding convening provider requirements to GFEs for covered individuals may create
unnecessary delays in patient care

From a coding and reimbursement standpoint, an AEOB is similar to a pre-claim or pre-service costestimate, generated to outline benefits and patient cost-sharing amounts prior to a patient
receiving a particular item or service. In this way, health plans will utilize GFEs from providers in asimilar manner claims are used post-care to create EOBs. Under the NSA, AEOBs will be createdutilizing the GFE submitted by the provider which, according to regulation, is required to include all
items or services reasonably expected to be furnished in connection with the patient’s care,including those from other providers and facilities.

For uninsured or self-pay patients, this process is challenging. It requires communication between
convening and co-entities at a level and pace that has proven difficult both to facilitate andmaintain, given the constraints of the current healthcare environment. Although providers continue
to develop potential solutions to these system inefficiencies, the application of a convening provider
framework to GFEs for covered individuals will be exceedingly more difficult to navigate. As stated,comprehensive cost estimates for covered individuals will require extensive administrative staff
time to complete in accordance with the regulation. It will also require the development andadoption of data transfer standards between insurers and both contracted and non-participating
providers.
It should also be noted the information exchanged between providers and health plans is far more
complex than the information required to develop a cost estimate for an uninsured or self-pay
individual. For instance, the collection of information on patient demographics, diagnoses,
anticipated services, charge rates and any applicable discounts should be sufficient to develop anaccurate cost estimate for an uninsured patient. However, for an insured patient, such information
is markedly incomplete from a claims adjudication standpoint. The proper application of2Cohen RA and Cha AE. Health insurance coverage: Early release of quarterly estimates from the National

Health Interview Survey, January 2021–March 2022. National Center for Health Statistics.
https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly_Estimates_2022_Q11.pdf. July 2022. Accessed
October 14, 2022.

adjudication-related coding information such as procedure codes, modifiers, diagnostic codes, placeof service and revenue codes, within the context of plan terms (and contract terms, whenapplicable), significantly impact an individual’s coverage for certain items or services. Therefore,both the submitting provider and the health plan must ensure processes are in place to aggregate
and process this information accurately, consistently and efficiently.
Furthermore, many common episodes of care will include the involvement of both professional andfacility providers. The forms and electronic transaction standards used to communicate claims
information are unique to each provider type, with different data inputs, formats and coding.
Should the convening provider framework be implemented in such circumstances, it would resultin a significant amount of data that must be aggregated by a single provider – regardless of theirfamiliarity with a particular claim standard or data set – to accurately reflect the episode of care so
the health plan may appropriately determine coverage and patient cost-sharing.
Such a process would be cumbersome, resource draining and highly susceptible to error, not tomention impossible in some circumstances. Foreseeably, it may also create further systeminefficiencies and delay patient access to essential healthcare services as providers and facilities
would require additional time to schedule, coordinate and deliver healthcare services.

Currently, each provider involved in an episode of care may submit a pre-claim to the patient’s
health insurer for benefit determination prior to the item or service being rendered. The healthplan receives and processes this information by provider type, forwarding an estimate of coverage,benefits and cost-sharing to the patient. The provisions of the NSA specific to GFEs for insured
individuals and the creation of AEOBs would not prohibit this methodology from being applied hereas well. Indeed, it would eliminate the burden placed on a single or convening provider from being
held accountable for the submission of GFEs for all providers and facilities involved in the episodeof care. Therefore, AAOMS encourages CMS to adopt a standard that would allow each billingprovider to submit a GFE to a patient’s health plan to help reduce provider burden..

Small practices and solo providers will face challenges in the implementation of new industry
transaction standards

Although the development and adoption of a HIPAA administrative standard is undoubtedly
necessary for the transmission of good faith estimate information from providers to health plans,
technology platforms such as Health Level 7 (HL7) Fast Healthcare Interoperability Resources(FHIR) and the deployment of FHIR-based Application Programming Interfaces (APIs) may be costprohibitive for small practices or solo providers, including OMSs.
Although OMSs treat patients in a variety of care settings, most are primarily office-based,
functioning within the constraints of smaller practice settings. Many OMS practice management
software solutions already include medical billing capabilities, which may be leveraged to support
the transmission of cost estimate information for GFEs and AEOBs through FHIR-based APIs.
Taking advantage of existing mechanisms in this way, particularly by adapting well-establishedprocesses with which providers across all specialties are well versed, would help to reduce
administrative waste and lessen the strain on financial resources.

Despite this, the cost of implementing new transaction standards, operating rules and software
applications will still be significant. Cost may also vary, depending on the individual practice needs,
current software and the requirements established by CMS. Although AAOMS believes this to be anecessary investment to help facilitate meaningful and accurate cost transparency, any added
burden on scarce resources threatens small business owners, particularly those in healthcare, tomake difficult decisions that may ultimately impact access to quality healthcare services. As such,
AAOMS encourages CMS and other federal agencies to consider targeting assistance, such as
payment incentives and technical support, to smaller healthcare practices and solo
providers to facilitate the adoption of new technologies.
Lastly, in the implementation of remaining GFE and advanced cost estimate provisions,
AAOMS encourages CMS to consider the following:
••

•

•

Implementation guidance must address instances in which health plans andproviders must engage in multiple communications concerning the adjudication of apre-service estimate. This is a frequent occurrence and, while feasible by claims
processing standards, regulatory timeframes for advanced EOBs make such
communications unworkable.
It remains unclear as to how advance cost estimates will be handled for coveredindividuals when multiple health plans are involved. Coordination of benefits
between carriers is a multi-stage process that is likely not feasible given the time
constraints for GFEs and AEOBs.
Clear and targeted education and outreach will ensure stakeholders across theindustry fully understand the requirements related to the transmission of good faithestimate information between providers and health plans. This will also aid
providers and healthcare managers to train and educate staff responsible for thecompletion of GFEs for covered individuals in accordance with the regulation.
Providers will need sufficient time to upgrade their systems and incorporate newworkflows.

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,

Paul J. Schwartz, DMD
AAOMS President

Joshua E. Everts, DDS, MD, FACS
Chair, AAOMS Committee on Healthcare Policy, Coding & Reimbursement