The Costliest Mistake in Price Transparency: Posting Incomplete Good Faith Estimates (45 CFR § 149.610(b))

For uninsured and self-pay patients, the good faith estimate is often the only tool they have to understand what care will cost. Under 45 CFR 149.610(b), small practices are required to determine who is uninsured or self-pay, treat cost questions as good faith estimate requests, coordinate with co-providers, and deliver estimates within tight timelines.

The most expensive error is not failing to offer an estimate at all. It is issuing an incomplete estimate that omits key services, co-provider charges, or required disclosures. When bills later show hundreds of dollars in charges that were never listed, patients can trigger the federal patient–provider dispute resolution process if their bill is at least 400 dollars above the estimate, putting your revenue and reputation at risk.

A complete good faith estimate is built on two pillars. First, the process duties in 45 CFR 149.610(b), which require convening providers to identify self-pay patients, reach out to co-providers within one business day, update estimates when scope changes, and manage recurring services. Second, the content rules in 45 CFR 149.610(c), which specify exactly what information an estimate must contain.

By designing workflows that capture every required element and by banning partial estimates that “we will fix later,” small practices can avoid the costliest mistake in price transparency while also improving patient trust.

Most small practices understand that the No Surprises Act created new consumer protections against unexpected medical bills. What is less obvious is how quickly an incomplete good faith estimate can turn a well-meaning attempt at transparency into a liability. A printed sheet that lists only the office fee but omits the lab draw, x-ray, or anesthesia is not just unhelpful. It can be evidence that the practice failed to follow 45 CFR 149.610(b) and (c).

The question is not whether you use fancy software or sophisticated actuarial tables. Regulators expect small practices to have a reliable process that captures all reasonably expected items and services, including those furnished by co-providers, and that does so within the deadlines set in 45 CFR 149.610(b)(1)(vi). That process can be as simple as a shared template and a checklist, as long as it consistently produces complete estimates.

This topic matters for payer relationships as well. When uninsured or self-pay patients escalate complaints, payers and regulators often review your entire billing and communication pattern. Demonstrating that you have a disciplined approach to complete good faith estimates under 45 CFR 149.610(b) lowers the chance that a single angry patient turns into a broader audit.

Understanding Legal Framework & Scope Under 45 CFR 149.610(b)

45 CFR 149.610(b) sets out the operational duties of providers and facilities. It tells you who must do what and when, especially for uninsured or self-pay individuals. Several key points define the scope for small practices.

First, the regulation requires convening providers to determine whether a patient is uninsured or self-pay, which means asking about coverage and whether the patient plans to use it for the primary item or service. If the patient is uninsured or opts out of using coverage, 45 CFR 149.610(b)(1)(iii) requires you to inform them that a good faith estimate is available whenever they schedule or ask about costs, using both written and oral notices that are clear, accessible, and posted where scheduling occurs.

Second, 45 CFR 149.610(b)(1)(iv) states that any discussion or inquiry about potential costs must be treated as a request for a good faith estimate. That means you cannot treat a detailed pricing conversation as “informal” while postponing the formal estimate for later.

Third, 45 CFR 149.610(b)(1)(v) and (b)(2) impose a coordination duty. The convening provider must, within one business day of scheduling or receiving a request, contact all co-providers and co-facilities that are reasonably expected to furnish items or services in conjunction with the primary service and request their estimate data. Co-providers are required to respond within one business day.

Fourth, 45 CFR 149.610(b)(1)(vi) sets the delivery deadlines.

• If the service is scheduled 3 to 9 business days in advance, the estimate must be provided within 1 business day of scheduling.

• If the service is scheduled at least 10 business days in advance, the estimate must be provided within 3 business days.

• If the patient simply requests an estimate, it must be provided within 3 business days of the request.

Finally, 45 CFR 149.610(b)(1)(vii) to (b)(1)(x) require updated estimates when scope changes, set rules for replacement providers and co-providers, and permit a single estimate for recurring care up to 12 months if the expected frequency and duration are clearly described.

Content completeness is then defined in 45 CFR 149.610(c). This subsection requires, among other things, a grouped list of all reasonably expected items and services by provider or facility, associated codes and expected charges, disclaimers about additional services and variation, and notice of the patient’s right to dispute bills that substantially exceed the estimate.

Understanding how these subsections fit together makes it easier to see that “incomplete” does not just mean “we forgot a line item.” It means failing to follow the entire process that 45 CFR 149.610(b) outlines for identifying self-pay individuals, coordinating with other providers, updating estimates, and fully populating the required content fields.

Enforcement of the good faith estimate rules falls primarily on the Department of Health and Human Services through CMS and related agencies, since the requirements flow from the No Surprises Act. States may also have their own price transparency laws and complaint processes that interact with federal rules.

Typical enforcement and review triggers related to incomplete GFEs include:

• Complaints from uninsured or self-pay patients who received an estimate that listed only a base fee, while final bills contained separate charges for ancillary services, facility fees, or co-provider work that were never mentioned.

• Cases where the billed charges for a single provider or facility end up at least 400 dollars higher than the expected charges on the GFE, leading the patient to initiate the federal patient–provider dispute resolution process under 45 CFR 149.620.

• Evidence that the practice routinely fails to treat cost inquiries as GFE requests, or does not collect co-provider data within the one-business-day window, which suggests systemic noncompliance with 45 CFR 149.610(b).

Regulators may respond with technical assistance, corrective action plans, or civil monetary penalties in more serious or repeated cases, especially where incomplete estimates lead to patterns of large surprise balances. For a small practice, the reputational damage from being viewed as opaque or misleading on costs can be as harmful as any formal enforcement action.

Even though the good faith estimate rule is part of the No Surprises Act and not HIPAA, price transparency and patient communication are increasingly reviewed alongside privacy and security. The following controls help a small practice survive an audit of its GFE process and avoid incomplete estimates under 45 CFR 149.610(b).

1. Turn every cost question into a documented GFE request

Many incomplete GFEs begin with an informal phone conversation that never gets captured as an official request. 45 CFR 149.610(b)(1)(iv) requires convening providers to treat any inquiry about potential costs as a request for a good faith estimate.

• Implementation: Update your intake scripts so that any uninsured or self-pay patient who asks “How much will this cost” is automatically logged in your system as a GFE request, triggering the standard workflow.

• Evidence: Saved scripts, EHR screenshots showing a “GFE requested” flag, and a log of requests with dates and responsible staff.

• Low cost: Use a simple shared spreadsheet or low-cost task manager to capture requests and due dates.

This control reduces the risk that staff handle cost conversations informally, then send hurried, incomplete estimates later.

2. Build a co-provider coordination log

A major completeness gap arises when the convening provider does not capture expected charges from co-providers. Under 45 CFR 149.610(b)(1)(v) and (b)(2)(i), convening providers must contact co-providers within one business day and co-providers must send back GFE data within one business day of the request.

• Implementation: For procedures that routinely involve multiple professionals or facilities, create a standing list of likely co-providers and co-facilities. When a case is scheduled, staff send a standardized GFE data request and record responses in a simple log.

• Evidence: Copies of outgoing requests, time stamped responses, and the log showing that co-provider charges were incorporated into the final GFE.

• Low cost: Use email templates and a shared spreadsheet that tracks request date, response date, and whether data were included in the estimate.

By systematizing co-provider coordination, you avoid the all-too-common situation where the GFE lists only the convening provider’s fee and leaves out anesthesia, imaging, or lab work that the rule expects you to include.

3. Use a completeness checklist tied to 45 CFR 149.610(c)

Before any estimate goes out the door, a staff member should confirm that all required content elements are present. 45 CFR 149.610(c) requires patient identifiers, a description of the primary item or service, a grouped list of reasonably expected items and services for the period of care, associated codes and expected charges, provider identifiers, and specific disclaimers and dispute resolution information.

• Implementation: Add a one-page checklist to your GFE template that mirrors the regulation. The person sending the estimate must tick each item and sign or initial the checklist.

• Evidence: Completed checklists attached to each GFE in the record; periodic internal reviews showing high completion rates.

• Low cost: Print the checklist on the back of the GFE form or embed it as a final section in your electronic template, so staff cannot skip it.

A simple checklist is one of the fastest ways to catch missing co-provider entries, missing codes, or absent disclaimers before an auditor or patient does.

4. Standardize recurring care estimates

For recurring care such as physical therapy, counseling, or chronic disease management, incomplete GFEs often show only the first visit. 45 CFR 149.610(b)(1)(x) allows a single estimate for recurring primary items or services, but only if it clearly describes timeframes, frequency, and the total number of expected visits within a period of up to 12 months.

• Implementation: For each common recurring service line, build a standard scenario. For example, “12 weekly counseling sessions over 3 months at X dollars per session” or “10 physical therapy sessions over 2 months.” Incorporate that pattern into the GFE template when such care is scheduled.

• Evidence: Example GFEs that show recurring care described with frequency and total visits; written protocols describing how staff choose the scenario.

• Low cost: Maintain a one-page “recurring care menu” with common patterns and prices that staff can copy into the estimate.

This control makes your recurring GFEs much more complete and prevents disputes where patients thought the estimate covered a multi-month plan, but it really described only one visit.

5. Enforce update rules when the plan changes

Clinical plans often change. 45 CFR 149.610(b)(1)(vii) requires convening providers to issue a new GFE when they anticipate changes to the expected charges, items, services, frequency, or providers, and to do so at least one business day before services are furnished.

• Implementation: Embed a simple rule in your scheduling system. When a provider adds substantial services, changes the site of care, or replaces a co-provider, staff must ask whether the GFE needs to be updated and, if so, send the new estimate.

• Evidence: Examples of original and revised GFEs in the record, along with notes explaining why the change was made and when.

• Low cost: Use a yes or no pop-up question in your EHR or a required field on your scheduling change form that asks, “Does this change require a revised GFE.”

By normalizing updated estimates instead of treating them as rare exceptions, you reduce the gap between expected and final charges and lower the risk of crossing the 400 dollar dispute threshold.

6. Audit a small sample of GFEs every quarter

Finally, 45 CFR 149.610(e) and (f) treat GFEs as part of the medical record and require that they be maintained and retrievable. Regular sampling helps you catch patterns of incompleteness before regulators or patients do.

• Implementation: Once a quarter, select a small random sample of GFEs, pull the associated charts and bills, and ask three questions: Was the patient correctly identified as uninsured or self-pay, were all co-provider services reasonably captured, and did the final bill track closely to the estimate.

• Evidence: Written audit summaries, lists of corrective actions, and any updated training materials.

• Low cost: The practice manager or billing lead can perform this review in a single afternoon, focusing on higher value or higher complexity services.

Routine mini-audits show that you take price transparency seriously and treat GFEs not as one-off paperwork, but as a core part of your compliance program.

Case Study

A small orthopedic practice offered outpatient joint injections and minor procedures at an ambulatory center. For uninsured patients, staff provided a one-page sheet listing a “procedure fee” of 900 dollars but omitted separate charges for facility use, anesthesia, and imaging guidance. Co-provider and facility charges were routinely left off because the practice relied on old verbal arrangements and had no process to collect GFE data from the anesthesia group or imaging center.

One uninsured patient scheduled a procedure four weeks in advance and received the 900 dollar estimate, which staff described as an “all in” quote. The actual bills told a different story. The orthopedic group billed 900 dollars, the anesthesia group billed 650 dollars, the imaging center billed 450 dollars, and the facility billed 750 dollars, for a total of 2,750 dollars. None of the ancillary charges appeared on the GFE.

The patient filed a complaint and initiated the patient–provider dispute resolution process. The dispute resolution entity requested the GFE and all related records. The estimate clearly failed to reflect all reasonably expected items and services that should have been coordinated under 45 CFR 149.610(b)(1)(v) and (b)(2) and listed under 149.610(c)(1)(iii). For the convening provider and the facility, the billed charges were more than 400 dollars above the expected charges shown on the incomplete GFE, meeting the threshold under 45 CFR 149.620.

The resolution entity reduced the amount the patient owed closer to what would have been reasonable based on a complete estimate and recommended that the providers implement a compliant GFE process. The anesthesia group and imaging center were also pulled into the review.

After this outcome, the orthopedic practice:

• Adopted a shared GFE template that required co-provider information and codes.

• Set up a coordination log to ensure that the facility, anesthesia group, and imaging center responded within one business day to GFE data requests.

• Implemented quarterly audits comparing estimates to final bills and used findings to refine scenarios for common procedures.

Within six months, patient complaints about surprise balances dropped sharply, and the practice could demonstrate clear alignment with 45 CFR 149.610(b) expectations.

A short self-audit against these tasks helps a small clinic confirm that its GFE process is not only timely, but also complete in the way 45 CFR 149.610(b) and (c) envision.

Common Audit Pitfalls to Avoid Under 45 CFR 149.610(b)

Regulators and dispute resolution entities tend to focus on a familiar set of errors when reviewing GFEs. Addressing them directly will reduce your risk.

• Treating detailed cost discussions as “informal” and never logging them as GFE requests. Error: ignoring 45 CFR 149.610(b)(1)(iv). Consequence: patients receive bills that differ from what they were told verbally and can argue that the practice failed to provide the required to be written estimate.

• Sending estimates that show only the convening provider’s fee with no mention of reasonably expected co-provider or facility charges. Error: failing to coordinate and include co-provider data as required by 45 CFR 149.610(b)(1)(v), (b)(2), and 149.610(c)(1)(iii). Consequence: large discrepancies between the GFE and final bill, increasing the likelihood of disputes over 400 dollars.

• Omitting key content elements, such as codes, provider identifiers, or dispute resolution information. Error: incomplete content under 45 CFR 149.610(c)(1). Consequence: regulators may consider the estimate noncompliant, and patients may claim they were not informed of their rights under 45 CFR 149.620.

• Ignoring meaningful changes in the plan of care and failing to issue revised GFEs. Error: violating 45 CFR 149.610(b)(1)(vii) to (b)(1)(ix). Consequence: final bills reflect services that differ significantly from what was described, which undermines the “good faith” nature of the estimate.

• Providing recurring care estimates for only the first visit rather than the full expected course of treatment. Error: misusing or ignoring 45 CFR 149.610(b)(1)(x) on recurring services. Consequence: patients may see each additional visit as an unanticipated charge, even when it was clinically planned from the start.

By treating these pitfalls as design problems in your workflow and template, you can systematically reduce incomplete GFEs and lower your exposure under the No Surprises Act.

Avoiding incomplete GFEs requires more than a good form. It requires a culture where price transparency is seen as part of ethical care and not as a burden. Designating a single point of contact for No Surprises Act and GFE compliance, even on a part-time basis, helps keep 45 CFR 149.610(b) duties visible.

Short, focused training sessions can align staff. Front desk teams should know when and how to log GFE requests. Schedulers should be comfortable coordinating with co-providers. Clinicians should understand that changing the plan may require a revised estimate. Billing staff should be equipped to explain how the GFE was constructed and how it compares to the final bill. Simple metrics such as the number of GFEs issued, the percentage with all required fields completed, and the number of disputes or complaints can give leadership a quick view of program health.

When leadership demonstrates that complete GFEs protect both patients and the practice, staff are more likely to follow the process carefully rather than rushing out partial numbers.

The costliest mistake in price transparency is not the lack of a glossy price list. It is sending patients incomplete good faith estimates that fail to capture all reasonably expected items and services or omit required information. Under 45 CFR 149.610(b), small practices are expected to identify self-pay patients, treat cost inquiries as GFE requests, coordinate with co-providers, and issue timely, complete estimates that meet the content rules in 149.610(c).

By tightening your workflows around these duties, you reduce the risk of 400 dollar-plus gaps that trigger the patient–provider dispute resolution process, and you build stronger relationships with patients who feel respected and informed.

Immediate next steps for a small clinic:

1. Rewrite your internal policy to ban partial or “draft” GFEs and require a completeness check against 45 CFR 149.610(c) before estimates are sent.

2. Stand up a basic co-provider coordination process that documents one-business-day outreach and follow-up for shared cases.

3. Update your templates for recurring care so that frequency, timeframe, and total expected visits are always specified when you rely on 45 CFR 149.610(b)(1)(x).

4. Schedule a quarterly mini-audit comparing a handful of GFEs to final bills to identify where information is still being left out.

5. Provide a short staff huddle training that walks through one complete GFE from request to final documentation, highlighting where incompleteness tends to creep in.

Recommended compliance tool:

A one page GFE completeness checklist, attached to every estimate and aligned directly with each element in 45 CFR 149.610(b) and 149.610(c).

Advice: Pick your three most common procedures this month and require that every uninsured or self-pay patient receiving them gets a fully completed, checklist verified good faith estimate before the visit.

• 45 CFR 149.610 Requirements for Provision of Good Faith Estimates of Expected Charges for Uninsured or Self-Pay Individuals (eCFR)

• Good Faith Estimates and Patient–Provider Dispute Resolution Requirements Slides (CMS)  

• Understanding the Good Faith Estimate and Dispute Resolution Process (CMS Technical Assistance) 

• Good Faith Estimate Patient–Provider Dispute Resolution Guidance for Individuals (CMS)

• What Is a Good Faith Estimate (Consumer Guide)

• The No Surprises Act’s Good Faith Estimates and Patient–Provider Dispute Resolution Overview