Price transparency beyond a chargemaster.

In today’s healthcare market consumers rarely know what they will owe for services until after they’ve received them. Use price transparency as a competitive differentiator while also complying with CMS rules for Medicaid FY 2019 IPPS/LTCH PPS with a true and accurate picture in real-time.

A look at the problem

Price transparency has been a longstanding issue for uninsured patients, but growing enrollment in high deductible plans and coinsurance plans is creating a greater demand for meaningful price information for insured patients. Consumers want to know what they will owe before they owe it, so they can determine how they will pay for it and what their options are.

Often, not knowing this upfront has negative impacts on their health outcomes. According to a recent Gallup survey, “one in three Americans say they have put off getting medical treatment that they or their family members need because of cost.” Variation in pricing for medical treatments and what plans cover is confusing, making consumers fear a needed treatment is too expensive.

Health care “shoppers” are more likely to receive regular medical treatment — and the vast majority of them find price information from unqualified sources like friends, family or clinical staff. If you don’t offer consumer-friendly price transparency tools, your patients may be getting less than accurate estimates of their financial responsibility, making them less likely to be able to pay at point-of-service.

Source: PriceWaterhouseCoopers (2015). Money Matters: Billing and Payment for a New Health Economy. Health Research Institute.

Where consumers have tried to find price information

  • A friend, relative or colleague 50% 50%
  • A receptionist or doctor’s office staff 47% 47%
  • Their insurance company 45% 45%
  • A doctor 45% 45%
  • A hospital’s billing department 35% 35%
  • A nurse 30% 30%
  • The internet, other than payer’s website 18% 18%

The advantages of price transparency

Consumers want it, typically because they are trying to understand what they will owe or they are price-shopping. It’s also good business, because patients who understand what they will owe are more likely to be able to pay for care. Plus a full 39 states currently have laws mandating that you make your prices available, and CMS has just released rules that require these charges be posted on your website in a machine-readable format by January 1, 2019.

Consumer demand

Your consumers want an accurate understanding of what they’ll owe for services before they’re rendered so they can plan financially. Prepare them for their out-of-pocket responsibility and they’ll be more likely to visit you instead of a competitor who doesn’t do so.

Good business

The earlier you begin the collection process, the higher the likelihood that you’ll eventually collect. This process begins with providing your patients with an accurate picture of their out-of-pocket responsibility so they can financially prepare to pay for services, either through payment plans or financing.

Government regulation

39 states currently have laws mandating that providers make their prices available to patients, including laws in 20 states that require pricing to be available on your website. CMS’s Meaningful Measures now require that you list standard charges via the Internet in a machine readable formate.

Your CMS readiness checklist

Frequently Asked Questions regarding requirements for hospitals to make public a list of their standard charges via the internet. 

What format is a hospital required to use to make public a list of their standard charges via the internet?

The format is the hospital’s choice as long as the information represents the hospital’s current standard charges as reflected in its chargemaster.

What is the definition of “machine-readable” for purposes of the requirements?

By definition, machine readable format is a digitally accessible document but more narrowly defined to include only formats that can be easily imported/read into a computer system (e.g., XML, CSV). A PDF, on the other hand, can be a digitally accessible document but cannot be easily imported/read into a computer system.

Do the requirements apply to all items and services provided by the hospital or does it apply only to specific services?

The current requirements apply to all items and services provided by the hospital.

What hospitals are required to make public a list of their standard charges via the Internet?

In the FY 2015 IPPS/LTCH proposed rule and final rule (79 FR 28169 and 79 FR 50146, respectively), CMS noted that section 2718(e) of the Public Health Service Act, which was enacted as part of the Affordable Care Act, requires that each hospital operating within the United States, for each year, establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital. There are no hospitals operating within the United States with exemptions from this requirement under the current policy.

Do the requirements restrict a hospital from posting quality information or additional price transparency information?

CMS encourages hospitals to undertake efforts to engage in consumer friendly communication of their charges to help patients understand what their potential financial liability might be for services they obtain at the hospital, and to enable patients to compare charges for similar services across hospitals. A hospital is not precluded from posting quality information or price transparency information in addition to its current standard charges in its chargemaster.

Does participation in a state online price transparency initiative satisfy the federal requirements?

CMS is fully supportive of and encourages state price transparency initiatives. However, under the current guidelines, participation in an online state price transparency initiative does not exempt a hospital from the requirements.

A consumer-focused price calculator

MySurePayHealth™ is a self-service web application that is white-labeled and embedded directly into your website. It automatically pulls an individually-tailored estimate from the most currently available levels of coverage. Our rules engine automatically queries, retrieves and merges data from payers with your charge master data and payer contracts. We obtain coverage details down to the individual plan and service type level, with the output being a highly accurate estimate of patient benefits.

With MySurePayHealth™ you have the ability to engage consumers in meaningful dialogue, steering those with high deductibles and self-pay to view payment plan options or to schedule time with one of your financial counselors. Armed with clear, accurate information about how much they will need to pay, your consumers can better plan for their medical needs and potentially reduce your bad debt and charity write-offs.

Provide accurate estimates.

MySurePayHealth allows patients to get self-service pricing information with minimal input data to get accurate estimates in real-time directly on your website anytime, anywhere.

Help patients plan.

Deductibles have tripled in the last decade and high-deductible plans continue to grow. Patients have a higher financial obligation than ever before. Providers who discuss costs prior to care double their likelihood of getting paid.

Improve the experience.

Giving patients their true out-of-pocket cost increases their satisfaction, and also the likelihood that they’ll arrive prepared to pay because of the foreknowledge and ability to financially plan ahead.

Increase your portal usage.

Online estimate traffic helps achieve meaningful use patient portal usage requirements. MySurePayHealth™ is embedded as a widget directly into your website or portal so you deliver a seamless experience.

Decrease manual inquiries.

With minimal input, your patients can generate an estimate from your website using the most currently available individual coverage, significantly reducing incoming calls.

Achieve price transparency.

Recent CMS rules for inpatient and outpatient price transparency initiatives require you to post charges. We think this isn’t comprehensive and could be potentially misleading to patients, resulting in avoidance of care.

Higher out-of-pocket costs are compelling patients to compare what different providers will charge them. You have to have that information for them to consider your facility.

Recondo pulls info that isn’t easily obtained. It gets everything out there, including what we need to estimate the patient’s financial responsibility. I would absolutely recommend this product. Working with Recondo, everything goes smoothly. Best of all, we’ve seen our point-of-service collections steadily increase.

Betty Wikoff

Mercy Health

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