Health Insurance Price Transparency: What's The Status?
My long time wish of fee-schedule transparency has mostly come true. Fee Schedules are the actual cost of services when using insurance- it is the price agreed upon between a provider (doctor, hospital, office) and insurance companies. For example, when your deductible is not met and you receive a bill for an amount that seems arbitrary (i.e. $103.67 for a visit with your doctor), this is a price listed on the Fee Schedule for that specific service.
Now, when I say agreed upon, I mean the insurance companies send a list of prices and the provider decides if those rates are fair and financially feasible. If the provider agrees with accepting those rates, a contract is signed. That it what makes providers «In-Network.» When providers and insurance companies contract with each other, the provider signs a confidentiality agreement. I have signed many of these and when doing so, I essentially agreed that the information is private and cannot be shared with anyone. This prevented me from telling patients the exact amount they would owe, even though I had the information.
If all goes smoothly, I estimate this taking 3-5 more years for everything to be public, accessible, and consumable because there are over 10,000 procedure codes and each insurance company/policy/plan has different prices attached to each code.
To put things in perspective, this is the equivalent to going to a grocery store, buying an apple, checking out, and then being told the price. You already «bought» the apple, so there are no returns. The cost is a surprise and can vary based on what grocery store you go to, but you never know the exact price beforehand. This ruling creates a policy that says you are allowed to know the price of apples at every store, so you can make informed decisions BEFORE buying. Hospitals must display of at least 300 services that patients can schedule in advance.
Overall, this ruling is a step in the right direction. It states what exactly has to be shared with healthcare consumers:
1. The gross charge (Billed Amount)
2. The discounted cash price (When not using insurance)
3. The payer-specific negotiated charge that a hospital has negotiated
with a third-party payer (the insurance company) for an item or service.
With that being said, change takes time and there is a disgusting amount of data to sift through to make available to the public. If all goes smoothly, I estimate this taking 3-5 more years for everything to be public, accessible, and consumable because there are over 10,000 procedure codes and each insurance company/policy/plan has different prices attached to each code. in 2022, CMS found 70% of hospitals complied with both components of the Hospital Price Transparency Act which is a huge increase from 27% in 2021.
As of April 2023, CMS has issued more than 730 warning notices and 269 requests for Corrective Action Plans. CMS has imposed civil monetary penalties on four hospitals for noncompliance, which are posted and made publicly available on the CMS website. Every other hospital that was reviewed through a comprehensive compliance review has corrected its deficiencies or is in the process of doing so.
Here are some articles to get familiar with the ruling:
www.cms.gov/healthplan-price-transparency/public-data
www.ncsl.org/research/health/transparency-and-disclosure-health-costs.aspx
www.cms.gov/healthplan-price-transparency/consumers
www.cms.gov/files/document/hospital-price-transparency-frequently-asked-questions.pdf
File a Complaint or Ask a Question about the Ruling: