Informing Patients of Costs in Advance
CMS asked whether health care providers should be required to inform patients about how much out-of-pocket costs will be before providing that service.
The coalition answered that CMS should distinguish between unanticipated and scheduled care costs.
With unanticipated care, informing patients about their costs in advance could be a violation of the Emergency Medical Treatment and Labor Act (EMTALA) and could have negative consequences for patient care. EMTALA requires that patients receive a medical screening examination and stabilizing treatment without regard to financial means or insurance status. EMTALA prevents hospitals from signage in the emergency department regarding prepayment of fees or co-pays and deductibles which could have the effect of discouraging patients from receiving emergency care.
The coalition noted that it is difficult to know what a patient’s costs will be before they are properly diagnosed and stabilized. For example, in emergency care, two of the most common patient complaints are chest pain and abdominal pain. These symptoms could be caused by a large range of diagnoses that each require differing tests, exams, and treatments.
When care is scheduled in advance, the coalition believes that any requirements about price transparency should be narrowly tailored to not cause unreasonable regulatory burdens. The coalition also believes that any obligations on physicians and hospitals should be accompanied by similar obligations on insurers to achieve network adequacy standards and in-network contracting terms that are fair and reasonable.
The coalition urged CMS to make its coverage terms and conditions available to its consumers. It argued that the physician fee schedule should not be used as a marker to assess market-based reimbursement standards for Medicare. It noted that the HHS (Health and Human Services) Office of the Inspector General has acknowledged that neither Medicare nor the Medicaid fee schedule are appropriate references when defining “usual charges.”
Enforcement Mechanisms
CMS requested feedback on the most appropriate way for it to enforce price transparency requirements. They asked if hospitals should attest to meeting requirements in an agreement and how CMS should best assess compliance. CMS also asked whether it should impose civil money penalties on hospitals that fail to comply with making standard charges publicly available.
The coalition answered by saying that additional civil penalties are not appropriate because hospitals already face fraud and abuse potential penalties. The coalition suggested that Medicare Administrative Contractor (MAC) guidance and review would be an appropriate mechanism to address transparency issues.
Medigap Coverage
CMS requested input on how Medigap coverage affects patients’ understanding of out-of-pocket cost and the challenges that providers face in communicating information about these costs. CMS asked about the changes that should be made to support providers in informing patients about the costs associated with Medigap coverage.
The coalition said that Medigap should be required to provide the information about out-of-pocket costs, just as any other health plan provider. It argued that coordination of benefits and issues of primary versus supplemental insurance are best explained by the health plans themselves.
The medical groups also noted that physicians are unlikely to know that a patient has a Medigap policy, its terms and conditions, or have access to information about reimbursement until after the claim has already been adjudicated by the supplemental insurer. The coalition said that requiring a hospital or physician to explain the terms and conditions of Medigap policies would be an unreasonable regulatory burden.
