Congress is looking to address financial challenges confronting patients. So should we.
Surprise bills and price transparency are hot topics in Washington, D.C., these days. Several legislative solutions have been proposed.
One bill, the Lower Cost Health Care Act, would change the dynamics of the relationship between providers and health plans by eliminating common contractual provisions, such as socalled anti-tiering, anti-steering, most-favored nation and gag clauses, among other measures.
Another, the STOP Surprise Medical Bills Act of 2019, sets forth an optional binding arbitration process that would occur exclusively between the health plan and the provider in situations where payment is contested, removing patients from the process completely (an option that also could be included in the Lower Cost Health Care Act).
A third proposal, the House Energy and Commerce Committee’s No Surprises Act, would prohibit out-of-network facility-based providers from balance billing patients in situations where a patient can’t choose a provider.
All three would extend beyond emergency situations, subject out-of-network providers who balance bill in certain situations to civil monetary penalties and fines and pay providers the median in-network rate for any services where the surprise-bill ban applies.
Also, as of this writing, rumors are circulating that the Trump Administration plans to issue an executive order on price transparency that may or may not require hospitals and health plans to publish negotiated rates — possibly in the fall. It’s too soon to know what will happen on the federal front. If any of these proposals come to fruition, HFMA will provide interpretation and guidance to members, as always. But it’s important to know that none of these proposals obviate the need to put the fundamental building blocks of the patient financial experience in place, as outlined in HFMA’s price transparency guidelines and Patient Financial Communications Best Practices.
Building a solid foundation will help you prepare for potential new federal requirements, which often specify parameters for providing price information directly to patients (in addition to other elements that are not patient facing). For example, the Lower Health Care Cost Act would require providers and health plans to give patients good faith estimates of their expected out-of-pocket costs within 48 hours of a request.
More important, improving the patient financial experience is the right thing to do not only for your patients, but also for your organization and the healthcare industry, irrespective of federal action. It’s key to building loyalty and trust with patients and communities.
In the near future, HFMA will introduce a concrete, quantitative tool that will enable provider organizations to assess their progress in this area. We call it the Consumerism Maturity Model. Through a guided self-assessment process, the model gauges a provider’s overall capabilities and identifies specific areas for improvement. It incorporates the patient financial experience building blocks that a growing number of organizations have already adopted and supplements them with relevant revenue cycle metrics from HFMA’s MAP initiative as well as external metrics. We remain committed to providing resources that help members deliver a financial experience that meets consumers’ rising expectations.
