By Victoria Cunningham, RRT, CCM

For the past 40 years, patients have told me they are disgruntled with their healthcare because they are never sure what the cost will be for services or procedures. These countless conversations have caused me to reflect: Healthcare is a business, like any other. What other business provides services to customers without first disclosing either an estimated or firm price for those services?  From auto mechanics to aerospace engineering, most businesses are expected, some even required by law, to provide consumers with at least a cost estimate.  With medical fees so incredibly high, why aren’t doctors, hospitals and outpatient facilities expected to do the same?

Should “informed consent” forms include written cost estimates? At present, patients are asked to sign a financial agreement that includes a promise to pay whatever their insurance will not (assuming they have insurance).  They must also agree that if their insurance declines to pay, the patient will then be responsible for the entire bill. However, the actual amount of the bill is not part of the discussion!  Do we, as providers, exempt ourselves from this part of the conversation because it makes us feel uncomfortable to talk about money because our patients are at their most vulnerable?  At the same time, will patients sign anything just to get the medical care they need?

There are the rumblings of a seismic shift in patients’ attitudes about the cost of their healthcare services. In the years leading up to the COVID-19 pandemic, demand for elective surgeries was in decline. Aging Americans, who consume the most healthcare dollars, are better-informed and better educated than previous generations. More and more often, they are asking for prices of tests, procedures, and surgeries prior to consenting to those services. I predict we will see more of this behavior as patients are held to greater accountability for their own health and wellness.

This paradigm shift is also reflected in CMS’ expectations of third-party payers. The Affordable Care Act gave the American public the opportunity to easily cost-compare optional healthcare benefits as they shop health insurance plans. More recently, the enactment in July, 2022 of CMS 995-F, the Transparency in Coverage Rule requires insurers to disclose to consumers the prices for all covered items and services.

According to law firm Nexsen Pruet:

As of July 1, 2022, the Coverage Rule requires that health plans and health insurance issuers must publicly disclose pricing information for covered items and services in specified formats for plan or policy years beginning on or after January 1, 2022. Specifically, most group health care plans and issuers of a group or individual health insurance must disclose pricing information through machine-readable files made available on the plan’s or issuer’s website. The files must include (1) rates for all covered items and services between the plan or issuer and in-network providers, and (2) allowed amounts for, and billed charges from, out-of-network providers.

The Coverage Rule also requires that the website for accessing the files must be publicly available and free.  Additionally, there must not be any other conditions on accessing the website or files, including any requirements that users create a user account, password, or other credentials or requirements that they submit any personal information.

A few years ago, Medicare began sending its members patient satisfaction surveys. Are patients of the Baby Boomer generation, who question everything, dissatisfied with their unexpectedly high medical bills?  We already know the answer to that question, don’t we? Is it only a matter of time before Medicare requires that patients receive written estimates prior to scheduling their hospital or clinic visits?

Because I am sometimes the hopeful consumer/patient, and always a questioning Baby Boomer, I would be satisfied with that.

Victoria Cunningham, RRT, CCM
Select RT Consulting

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