The healthcare industry at large – and specifically legislation and best practices around patient payments – is changing rapidly. By now, most providers have heard of the No Surprises Act (NSA), but few fully understand its implications and what is coming next. Despite substantial requirements, workflow changes and possible fines and penalties, the notoriety for this sizable federal mandate among private healthcare practices has been less than one might expect. Since 2022, self-pay patients have required Good Faith Estimates (GFE) for each encounter. These requirements outline expected charges, services, and related cost allocations along with stringent mandatory disclosures before a patient receives care. Many healthcare practices, especially private practices, have failed to adopt this- especially not within the highly specific requirements set forth in the NSA.
The No Surprises Act comprises two major elements: surprise billing restrictions and the Good Faith Estimate requirements. Currently, Good Faith Estimates apply to self-pay patients; what many providers and administrators do not realize is that mandates are expected to be enacted for insured patients in the next six-to-12 months. This groundbreaking extension will make the No Surprises Act unavoidable, fundamentally reshaping how patient care is estimated, priced, and delivered. Although the measures implemented require attention now, this update will make the requirements impossible to ignore for all practices. Most healthcare organizations and providers view this as just another layer of bureaucratic red tape, slowing patient care and squeezing profitability. However, this perspective overlooks a timely opportunity. Early adopters can flip the script, transforming a burdensome mandate into a strategic advantage by boosting patient payments at the time of treatment, raising patient satisfaction, and driving greater operational predictability. Instead of becoming another nail in the coffin of physician and dentist-led practices, these measures may very well prove to be revenue boosters. Successful implementation depends on a simple formula, but every part is essential: transparency, accuracy, and true accessibility through flexible patient payment options.
Considering Options to Proposed CMS In-Network Workflow
The current CMS proposal for in-network workflow will not work, plain and simple. This proposal includes the requirement to create a GFE, transmit it electronically to the payer, who will then analyze and send an Advanced Explanation of Benefits - a confirmed and more detailed version of the GFE - to the patient. This would be akin to replicating the claim submission process before patient care, and anyone in this industry is familiar with the length of that process. CMS has signaled uncertainty, both through implementation delays and issuance of an RFI - or Request for Information, a formal process to obtain stakeholder feedback through specific implementation questions. The current process for self-pay and uninsured patients of providing a GFE directly to the patient has proven effective. As we illuminate the idiosyncrasies of this debate, it is important to note that the core goal of the No Surprises Act should be to help both patients and providers. These benefits, although not immediately apparent, are based on an age-old paradigm of providers not being paid for treatment. By protecting patients from surprise billing, this Act protects providers from unpaid bills. In this article, we explore these benefits, predict final workflows, and analyze case studies for the efficacy of Good Faith Estimates prior to treatment for patients before care, regardless of insurance coverage status.
As established, the proposed CMS workflow is untenable from a timeline and delivery standpoint; many notable organizations agree. The AMA stated that the timeline is often unworkable because the data needed to generate an accurate estimate, particularly for insured patients, is not available within the required timeframes. In addition, the American Hospital Association (AHA) warned that applying the same complex multi-provider GFE requirements to all patients - not just the uninsured or those opting out of insurance - would delay care significantly due to the increased administrative burdens and reliance on payers. To ensure realization of the value proposition described, we must look to the current workflow and historical industry standards. To understand today’s landscape, it is essential to recognize the profound influence of the coinsurance model over the past two decades. In dental coverage, coinsurance has long stood as the standard. Medical insurance, by contrast, has undergone a dramatic shift in the same period, with coinsurance becoming increasingly prevalent and aligning more closely with the dental paradigm.
Case Study One: Dental Industry Practice Increases Revenues
The dental model offers a clear case study. Dental insurance has long maintained a relatively predictable structure: typically espousing 0% coinsurance for preventive care, 20% for basic procedures, and 50% for major procedures. Medical insurance, by contrast, looked quite different a decade ago. In 2012, only about 27% of medical plans included any coinsurance (MEPS-IC). By 2023, that figure had climbed to more than 63%, per the Kaiser Foundation. During the same period, the levels of cost sharing also increased, leaving patients with larger balances and a higher risk of unexpected bills.
The implications are substantial: more disgruntled patients, rising levels of bad debt and deferred care, and costly billing and collection efforts. This trend not only impacts patients, but also undermines providers, threatening both financial stability and the trust at the core of the patient–doctor relationship.
To realize the potential benefits of Good Faith Estimates, we must first recognize the costs of patients entering treatment unaware of their financial liability. The No Surprises Act requires providers and facilities to give uninsured or self-pay patients a GFE for reasonably expected costs of planned services when scheduled at least three days in advance or upon request.
For providers, the U.S. Department of Health and Human Services noted that each paper statement costs $3–$5 in staff time, materials, and postage, often sent multiple times before payment. As balances age, collection rates plummet: only about 70% of charges are recovered after 90 days and less than 30% after 180 days, resulting in tens of thousands in annual write-offs for many practices. With credit bureaus no longer reporting negatively on healthcare debt, the chances of collecting after the fact continue to spiral. These hidden costs compound further through treatment abandonment, patient churn, and reputational damage.
Up-front transparency dramatically changes this equation. In Cedar’s national survey, more than 50% of consumers who received an estimate in advance said they would pay before the visit – a clear shift from reactive collections to proactive payment.TransUnion found 70% of patients said knowing the cost before having a medical procedure helped them budget for payments, and Banner Health documented a $17.8M increase in point-of-service collections within two years of implementing estimates. The evidence is clear: transparency not only reduces patient balances but also strengthens the financial and relational foundation between patients and providers.
When considering alternate approaches for implementing GFEs in the in-network setting, two case studies provide particularly useful guidance: the current self-pay and uninsured billing flow implemented today under the NSA, and the longstanding model of dental cost estimation. Revenue Cycle Management conversations and tools often center focus around insurance collections; however, the vast majority of bad debt Accounts Receivable are derived from patient balances. In fact, studies show that between 51-60% of bad debt in medical settings derives from the patient portion. Additionally, a sizable portion of practices report that up to 10% of total balances end up as bad debt. These numbers are astounding. For frame of reference, if 10% of products were simply unpaid for in a retail environment, or 10% of all restaurant tabs went unpaid, these businesses would fold. This paradigm is not dissimilar in healthcare and is a major driver of large corporations and hospitals buying up smaller practices. Even private equity and larger organizations are feeling the impact, reporting profitability margins far lower than expected in both medical and dental specialties. For example, the American Dental Association noted that dental practice revenues increased by 2.2% over the last decade, but expenses grew by 7.7%, leading to compressed margins. And while health system operating margins remained low, the U.S. health insurance industry's net income and profit margin dropped sharply to the lowest points in a decade, according to the National Association of Insurance Commissioners (NAIC).
With rising costs, the profitability is simply not there to write off 10% of patient payments. Dental fares significantly better. Despite relying more heavily on patient payments – both in terms of larger patient portions and a greater share of total income – dentists issue fewer patient bills and for a smaller percentage of total revenue than their medical counterparts. In fact, only about 40% of dental accounts receivable comes from patients, a figure that is drastically lower than those among medical doctors, even though dentistry operates in an environment with inherently higher risk of unpaid patient balances. It is well-established that, in both medical and dental, although administrative error and delayed filing issues lead to loss of insurance revenue, a higher percentage of accounts receivable (AR) balances on the patient side will never pay than that of the insurance side. Considering the credit bureau decision to no longer report on healthcare debt, this gap in patient AR collections is only widening
The goal of universal GFE implementation should be twofold: to streamline the flow of patient cost estimates and payments across healthcare, and to ensure compliance while protecting patients from unexpected financial liability. The evidence of the dental world being more efficient than the former is overwhelming and warrants a deeper comparative analysis. As medical deductibles and coinsurances have climbed, patient liabilities as percentages of total practice balances have grown since the early 2000s from roughly 5% to 35% or greater. This has significantly closed the gap with private dental practices, which are estimated to average around 40% of total expected balances deriving from patient liabilities.
Historically, higher patient out-of-pocket amounts have forged sturdy and replicable workflows in dentistry. Namely, after the initial consultation, dentists have typically created a full treatment plan, highlighted proposed procedures, and estimated costs. This amounts to a GFE without some of the modern disclosures and formatting, which has been standard practice for over four decades. Then, dental practices typically offer a range of payment options, including flexible payment options. Contrarily, medical specialties have traditionally accepted co-payments and billed out the remainder – not only leading to uncertainty in patient populations, but higher instances of unpaid balances. Additionally, flexible payment options have not been offered in medical practices. Practices are realizing the benefit of these options with rising patient liabilities, with 41% of medical groups upgrading payment plan options in the last year. One without the other is not enough – increasing payment options ought to be combined with more accurate estimates and increased price transparency ahead of treatment. Medical offices are signaling an understanding of the need to adapt, and Good Faith Estimates could provide the necessary guidance to evoke change in long-standing habits across most medical specialties. CMS can glean invaluable information from this case study, emulating this traditional dental flow has the chance to create a mutually beneficial model for both patients and providers.
Case Study Two: Providers Embrace Current GFE Self-Pay Workflow
The second case study, and even more directly applicable, is seen in the current GFE uninsured and self-pay workflow. Simply stated, providers work directly with patients to present a required GFE- allowing patients to receive the care they need without delays, while still having a clear estimate of cost before making any financial decisions. This is already proven; it is currently working and will have minimal opportunity cost to implement in front offices. Bad debt is rising across the industry; due to the multitude of factors discussed. However, self-pay and uninsured patients account for a disproportionally small portion of this bad debt. There are two indications that providing accurate, upfront cost estimates directly reduces bad debt for healthcare providers: The problematic history of the traditional fee-for-service model, where a lack of pricing transparency often led to unpaid bills, and the GFE requirements for self-pay patients, which reduces surprise billing and gives patients better financial information. This trend is becoming even more pronounced as technology makes cost estimates more accurate.
Many healthcare leaders have also recognized this as an opportunity early on: Stacy Bratcher, the vice president and general counsel at Cottage Health states “addressing financial issues up front, before care is delivered, creates opportunities for providers to avoid unpaid medical bills, reduce bad debt, and improve revenue cycle performance.” The logic of more transparency leading to more instances of patient payments carries over to in-network patients directly, especially with increasingly high and difficult to understand patient liabilities. Moreover, this transparency holds providers accountable and is driving up accuracy and even technology adoption by putting all the cards on the table – with patients being advised they can dispute estimated portion inaccuracies or lack of proper data and disclosures provided. On the other side, Independent Dispute Resolutions (IDR) from providers to challenge out-of-network (OON) reimbursement amounts are also permitted under the NSA. CMS reports that from April 15, 2022 through May 31, 2025, more than 3.32 million IDR disputes were initiated. These disputes drive up provider reimbursements and reaffirm the potential of the No Surprises Act to be a true win-win for practice owners, patients, and thus the healthcare industry at large.
Assessing this data and these case studies paints a clear picture of a path forward. The path is not one that has been publicly discussed by many, especially not among the larger organizations getting involved. In speaking to individual providers and stakeholders – especially in private practices – their opinions are clear that they agree with the vision of GFEs, but the proposed workflow for insured patients could be catastrophic. I propose that we emulate the historical dental and current self-pay or uninsured GFE flow that we have analyzed in this piece. This would mean that providers are permitted to provide GFEs directly to patients and then attach these GFEs to the eventual claim to allow for backend transparency and audit capabilities for payers. This plan will work for several reasons.
Creating Efficiency for Payers
This will allow payers to review GFEs and ensure they are within the accuracy thresholds at a macro level, without the pressure of holding up patient treatment. Auditing GFEs could be a highly automated, even AI-driven process – with the rules and requirements for accuracy already clearly defined by the NSA. The cost threshold for this will be substantially lower than the proposed workflow. Creating an AEOB for each patient is only the start of the time commitment to be taken on by payers. This will also prompt hundreds of thousands - if not millions - of communication threads with both patients and providers. Patients will be prompted to question every detail of cost to the payer, rather than the practice. When we look back at the dental model, the methodology of sitting with a patient to explain costs and treatments ahead of time has not only improved patient experience and understanding but also decreased billing costs and bad debt. On the contrary, patients communicating directly with payers before treatment will not only cost payers millions in support dollars, but will intrinsically lead to patient confusion, undermine the practice-patient relationship, and yield delayed and ultimately cancelled treatments.
Providers will be constantly riding payers to get AEOBs out faster so that they can treat patients. This will necessitate payer investment in the entire call center and support channels just for these request types. It will further erode the trust and working relationship between in-network providers and payers, and bottle neck revenues for practices at a time where they need procedures and timely payment more than ever.
Provider Control as a Catalyst for Patient Experience
As alluded to, providers with this proposed flow will be able to control their own destinies. They can innovate the patient experience through more sophisticated eligibility technologies and services and add advanced payment options to realize more efficient patient payments. This will encourage providers of all specialties, much like we described in the dental world, to sit down with patients and explain a plan of treatment with exact cost figures. Not only do the statistics indicate that this model yields more timely payments, but also patients are more likely to add more advanced treatment options and see the initial treatment through when this type of dialogue and planning occurs. In fact, a meta-analysis by Lindheim and colleagues found that patients involved in Shared Decision Making were 37% more likely to see treatment through.
As many private healthcare practices work to compete against efficiencies in larger corporations, this patient experience is paramount. Patients are significantly more likely to be pleased with medical treatments and clinical outcomes also improve with treatment planning, or Shared Decision. Lindheim's study also noted that these patients opted for additional sessions, preventive visits, or lifestyle programs at a far greater rate (Lindheim et al., Patient Preference and Adherence, 2014). In the transition of private healthcare’s focus on patient experience and convenience, we are seeing surges in business models such as holistic care, with more specialties under one roof, aesthetic and standard medical care integrations, concierge care, direct primary care and more, leading to an inflated value of both treatment planning and advanced payment options.
Proposed Workflow Provides Transparency
As made clear from the prior two sections, patients share these benefits in a true system of reciprocity. With the proposed workflow, patients will have transparency without suffering from delayed care. Additionally, providers will be more likely to offer flexible payment options- ensuring care is more accessible. Statistics show us that the paid-up patient is the happy patient; those who understand balances are not receiving surprise bills, switching doctors, or neglecting the care they need- they are coming back and bolstering the entire healthcare system in doing so.
Technology plays a key role in this recommended implementation. Advancing technology has brought us to the forefront of laser-accurate eligibility verification capabilities. The thinking behind sending a GFE to payers to then generate an AEOB is to ensure accuracy. With this technology, inserting this level of bureaucracy between providers and patients is not only unnecessary, but extremely costly to all parties. Using AI, ERAs are being scanned in real time to both train models on a macro scale on payer tendencies, but also on practice-specific schedules of fees. This allows real-time adaptation and accuracy beyond what legacy systems or even phone calls to the payers could often yield previously.
Allowing providers to own this process will necessitate an adoption of these technologies, which will lead to more accuracy, happier patients, and less bad debt for providers. Given the current landscape of rising bad debt and growing patient financial responsibility, providers will be strongly incentivized to adopt modern technologies within this approach. As a result, the industry will progress rather than remain constrained by the proposed CMS framework.
In summary, with the streamlined implementation described, advancing technology, treatment planning, and flexible payment options, providers, payers, and patients alike can declare victory. Advanced payment options will be a huge piece of this puzzle, making it imperative to empower patients with choices: paying their portion today, applying for financing, setting up an in-house payment plan, or securely guaranteeing balances on an encrypted credit card. In doing so, the healthcare industry can take another perceived stretch of red tape and turn it into a catalyst for much-needed change. GFEs are required in both medical and dental specialties - and although dentists hold a slight edge - mandatory disclosures, eligibility technology and widespread adoptions of flexible, friction-free payment capabilities are necessities across healthcare. In this environment of rising costs and increasing billing costs and bad debt, increasing frequency of payment and planning at the time of treatment is exactly the cure-all healthcare needs.
