In response to surprising billing concerns, one hospital advocate urged CMS to adopt provisions of a National Association of Insurance Commissioners model act on insurance network adequacy.
Sept. 13—The Senate will undertake a review of price transparency in health care next week, shortly after hospital advocates urged caution in Medicare’s transparency push.
The Senate Health, Education, Labor and Pensions Committee plans a Sept. 18 hearing titled “Reducing Health Care Costs: Examining How Transparency Can Lower Spending and Empower Patients.” The hearing will feature well-known healthcare transparency experts such as Leah Binder, president and CEO of the Leapfrog Group.
The hearing closely follows the Sept. 10 deadline established by the Centers for Medicare & Medicaid Services (CMS) for stakeholders to submit a series of transparency proposals. Hospital advocates generally urged caution in pursuing such proposals.
“In general, advancing price transparency has been challenging for the healthcare system due to the inherent uncertainty in the course of disease and treatment, as well as the need to share data and information across multiple payers and providers,” wrote the American Hospital Association.
In the FY19 Hospital Inpatient Prospective Payment System (IPPS) final rule, CMS required hospitals to make public a list of their standard charges via the Internet in a machine-readable format and to update this information at least annually.
To further price transparency, CMS sought comments about several other transparency issues:
- Barriers preventing providers from informing patients of their out-of-pocket costs
- Changes needed to support greater transparency around patient obligations for costs
- Ways to better inform patients of these obligations
- The role providers should play in this initiative
America’s Essential Hospitals (AEH), which represents safety net hospitals, said it supported sharing out-of-pocket costs with patients but warned that physicians might lack the knowledge or training to provide such information before treating a patient.
“Without a system in place to ensure that physicians can provide accurate calculations of out-of-pocket costs, this information is not useful for patients and could lead to confusion,” said Bruce Siegel, MD, president and CEO of AEH. “Further, requiring physicians to provide such information likely would increase administrative burden.”
Why Focus on Hospitals?
The Federation of American Hospitals (FAH), which represents for-profit hospitals, wondered why CMS was apparently focusing its price transparency efforts on hospitals when “payers—insurers, group health plans, Medicare, Medicare Advantage organizations, and others—are best suited to provide actionable coverage and cost-sharing information for all providers and suppliers involved in an episode of care.”
For the 90 percent of patients who are insured, “The payer is the only entity that is capable of providing a patient with an accurate and actionable estimate of their potential financial exposure for the entire episode of care.” The small share of uninsured patients could receive needed “individualized information through a provider’s financial counselors,” wrote Charles “Chip” Kahn, president and CEO of FAH.
FAH also opposed other possible approaches, such as:
- Requiring disclosure of median rates, discounts, or competitively sensitive information
- Creating a federal enforcement mechanism for existing requirements that hospitals establish, update, and make public “a list of the hospital’s standard charges for items and services provided by the hospital”
- Requiring hospitals to provide an estimate of the patient’s out-of-pocket costs before furnishing a service
If the goal of CMS is to address the increasingly high-profile issue of surprise medical billing, Kahn suggested the agency adopt the relevant section of the National Association of Insurance Commissioners’ Health Benefit Plan Network Access and Adequacy Model Act.
Among the provisions is that patients who receive emergency treatment from an out-of-network provider at an in-network facility would have their out-of-pocket costs limited to those of an in-network provider. Before any nonemergency treatment is scheduled, the model act requires the in-network hospital to provide the patient with a written notice stating that the patient might be treated by a provider that the patient’s plan determines to be out-of-network, and other information that includes a range of potential charges for such treatment.
The approach “provides real protection for patients by providing an important measure of transparency combined with reasonable protections of patients’ financial interests,” Kahn wrote.
Monday, Sept. 17
Webinar by the Centers for Medicare & Medicaid Services (CMS) titled “The IRF and LTCH Section N Follow-Up.” Learn more.
Tuesday, Sept. 18
Conference call by CMS titled “Dementia Care: Opioid Use & Impact for Persons Living with Dementia.” Learn more.
Webinar by America’s Health Insurance Plans titled “Driving Plan Performance with a Unified Consumer Experience.” Learn more.
Webinar by the Accreditation Association for Ambulatory Healthcare titled “Emergency Drills.” Learn more.
Comments due for the draft 2019 CMS Quality Reporting Document Architecture (QRDA) Category III Implementation Guide for eligible clinicians and eligible professionals. Learn more.
Webinar by Avalere and the Better Medicare Alliance titled “Medicare Advantage vs. Medicare FFS: Chronic Conditions Outcomes.” Learn more.
Wednesday, Sept. 19
Webinar by HFMA on 2019 proposed rule changes to the Outpatient Prospective Payment System (OPPS) and ambulatory service centers. Learn more.
Web conference by the Advisory Board titled “How to Meet the Needs of 18 Million (and Counting) Cancer Survivors.” Learn more.
Webinar by the American Hospital Association titled “The Importance of Forming a Diagnostic Management Team.” Learn more.
Webinar by CMS’s Hospital Outpatient Quality Reporting Outreach and Education Support Center titled “Discovery: Planet Data.” Learn more
Friday, Sept. 21
2018 Architecture of High Value Health Care National Conference hosted by The High Value Practice Academic Alliance and the AHA’s Health Research & Educational Trust, Baltimore. Learn more.
Deadline for comments on the draft of the 2019 CMS Quality Reporting Document Architecture. Learn more.
