In December, the Trump administration made two rules regarding medical costs disclosure as well as surprise billing:
The healthcare price disclosure rule went into effect this month. The rule mandates that hospitals disclose their privately negotiated charges with commercial health insurers and are required to publicly post their prices for three hundred of the most common services that can be scheduled in advance, such as elective procedures. Hospitals have to disclose what they’d be willing to accept if the patient were to pay in cash. It is supposed to include every component of the procedure. Keep in mind this does not effect the traditional Medicare or Medicaid federal program. Additionally, insurance plans and issuers are required to disclose in-network provider negotiated rates, historical network allowed amounts, and drug pricing information via three separate files on a publicly assessable website. The goal is to provide as much information to patients so they can make the best decision as to where to get their care.
Let's also review new rules surrounding surprise billing that go into effect in 2022. Surprise billing refers to bills patients receive after receiving care at an in-network facility however some of the services they were provided came from out-of-network providers. The out-of-network provider will send the bill to the patient’s insurance provider who then pays a certain amount for the bill. The remainder or balance of the bill becomes the patient's responsibility. Unfortunately, very few patients understand this practice and even fewer seek to determine who will be on their care team. The end result could leave a patient with the responsibility of tens of thousands of dollars.
Academic researchers have found that millions of Americans receive these types of bills each year. Not surprisingly, the majority of the surprise billings come from specialist that the patient cannot select such as anesthesiologists, emergency department physicians, and radiologists. Because these specialists have limited competition, and treatment necessities that are emergencies, urgent, or unplanned by patients, the practice of rejecting network contracts has become a lucrative business. And consequently, some private equity firms have turned this into a very robust business by buying emergency room doctor groups as well as other specialist and moving them out of network so they can bill larger fees.
The new legislation requires insurers and medical providers to use an outside arbiter if they cannot agree on a payment rate. The arbiter would determine a fair rate based on what other hospitals and doctors charge for similar procedures and services. In this instance the patients could realize the same kind of costs sharing they would pay for in-network services and nothing more. This legislation probably will not do much to lower medical costs, in part because of the struggle between private equity firms, hospitals, and doctors who benefit from this practice will continue to pour money into defeating the protections it will provide for patients. In the interim, these protections are welcomed by advocacy groups who had realized years of defeat.
Always keep up on the latest developments especially when a new Executive and Legislative branch starts to review prior rules. There may be changes to these two rules coming.
If you have financial questions related to your myeloma care, consider working with a Myeloma Coach who has experience in financial resources. Coaches are a myeloma patient or caregiver who has experience navigating the financial cost of treatment and can share what they've learned.
about the author
Diahanna is the Financial Program Manager for the HealthTree Foundation, specializing in financial help for multiple myeloma and AML patients. As a professional financial consultant and former caregiver of her husband who was diagnosed with multiple myeloma, Diahanna perfectly understands the financial issues facing myeloma patients.