A coalition of 12 medical groups sent a letter to the Centers for Medicare & Medicaid Services Administrator responding to a request for information on price transparency. The letter demanded transparency by insurance companies and called for them to make information on usual physician charges available to the public.
Request for Information
On May 7, 2018, the Centers for Medicare & Medicaid Services (CMS) published a proposal to revise the Medicare hospital inpatient prospective payment systems for FY2019. The proposed rule would establish new requirements or revise existing requirements for quality reporting by specific Medicare providers. CMS requested that any interested parties submit comments by June 25, 2018.
Specifically, CMS is proposing to update its requirements for hospitals based on Section 2718(e) of the Public Service Act, which requires hospitals to establish and update a list of the hospital’s standard charges for items and services provided by the hospital. CMS is concerned that patients are challenged by insufficient price transparency. For example, patients may be surprised when they receive out-of-network bills for hospital-based physicians who provide services at in-network hospitals.
CMS is proposing to require hospitals to make a list of their current standard charges available on the Internet and to keep it updated annually. CMS is also considering other actions that would help patients to understand what their potential costs may be for services they obtain at the hospital and allow patients to compare charges across hospitals.
Participating Organizations
Numerous organizations and individuals responded to the request for information. Of note was the letter sent by a coalition of medical organizations:
- American College of Emergency Physicians
- American Academy of Emergency Medicine
- American College of Osteopathic Emergency Physicians
- American College of Radiology
- American Psychiatric Association
- American Society of Anesthesiologists
- Emergency Department Practice Management Association
- Healthcare Business Management Association
- Medical Group Management Association
- Physicians for Fair Coverage
- Radiology Business Management Association
- Society for Academic Emergency Medicine
The American College of Emergency Physicians and Emergency Department Practice Management Association also sent separate comments to CMS on the topics of price transparency, regulation issues, and out-of-network costs.
Price Transparency From Insurers
The coalition congratulated CMS for its improved price transparency and accountability for patients. The coalition then offered several suggestions.
As to what types of information would be most beneficial for patients or how hospitals can best enable patients to use charge and cost information in their decision-making and how CMS and providers can help third parties create patient-friendly interfaces with the data—the coalition stated that it is payer’s responsibility provide clear information to consumers about coverage costs.
Patients, said the coalition, do not fully understand their health plans or what high deductible, co-insurance, deductibles, and co-pays mean.
It is unfair to place responsibility for providing cost and charge information exclusively on hospitals, physicians, or patients, said the medical groups. They argued that insurers should explain the manner and methodology that they use to adjudicate patient plan benefits in clear and specific terms.
Too often, they wrote, payers hide information saying that claim adjudication is proprietary or confidential.
The coalition explained that even if providers and hospitals are able to provide pricing information in advance to patients, this would accomplish little as far as transparency without accompanying information from insurers.
At a minimum, they wrote, patients should know whether a physician is in-network and whether they will pay the same cost if they have to receive unanticipated care from an out-of-network physician. Patients, in other words, should be provided with reasonable and timely access to in-network physicians.
The coalition suggested that the best information to provide to patients is the usual and customary (U&C) physician charge from a not-for-profit, independently owned and operated entity. Such an entity would provide patients access to an open and transparent database that collects physician charge data from actual claims information and makes that data commercially available to the public for consumption.
The coalition noted that FAIR Health, Inc. is the gold standard in databases and that it was found to be the best national U&C charges database to determine out of network reimbursements in two separate studies by the non-partisan and objective research organization at the University of Chicago.
