You may have heard about the new legislation surrounding “Price Transparency” in 2022, effective January 1. I put that in quotes for a reason. I may be a bit of a skeptic, but this new law is nothing more than insurance carriers pushing reimbursement rates lower with “price transparency” and “helping patients” as a rather opaque facade. Make no mistake, this is all BS. As my grandfather used to say, they are pissing in our ear and telling us it is raining.
Let me explain…
Disclaimer: IF you don’t care about the why/how/what/the ramblings of a disenfranchised biller and just want to know how to protect your practice, jump to the end of the article where I get to the solution post-rant.
What they say it’s about…
The concept behind the OPPS Price Transparency Final Rule (CMS-1717-F2) is simple: provide transparency that will help consumers understand medical costs and make informed decisions — like most other services they purchase. Source: https://www.experian.com/content/dam/marketing/na/healthcare/brochures/price-transparency-fact-sheet.pdf ? Oh, weird, they’re selling a calculation tool that just so happens to help. No skin in the game for them…
Health plan price transparency helps consumers know the cost of a covered item or service before receiving care…This pricing information can be used by third parties, such as researchers and app developers to help consumers better understand the costs associated with their health care. Source:
https://www.cms.gov/healthplan-price-transparency Nice little pointed summary from Uncle Sam completely ignoring the reality here. Standard BS operating procedure just like last year when all anyone talked about was “how easy it is to code E/M (consult) codes now” when the reality of the situation is every physician lost 11% in revenue for doing the exact same thing they did the year before. Oh, no one told you? Case in point my friends.
https://www.forbes.com/sites/debgordon/2021/08/29/biden-administration-delays-new-health-insurance-price-transparency-rules-at-least-6-months/?sh=75a956036a65 <— Nice little summary from Forbes – no trash talk from me here. I must also admit that there are some positive aspects to the law including posted in-network rates for carrier contracts and prescription drugs with historical data. ? for not being complete garbage…
What the rule “says”:
The final rule mandates that hospitals must publish the following by January 2022: A comprehensive machine-readable file for “Items and Services” offered by the hospital.
The standard file must include:
• Gross charges • Cash price for self-pay • Payer-specific negotiated charges
• De-identified minimum/maximum negotiated charges
A consumer-friendly (plain language), searchable list displaying the payer-specific rate for 300 shoppable services. “Shoppable” is defined by CMS as a service that can be scheduled in advance. CMS has already specified 70 services.
Boy, it sure sounds like they’re looking out for your bottom line right?!?
What the rule really says…
Right now, if a doctor sees a patient and doesn’t have a contract with __________________ (insert favorite crooked insurance company name), the reimbursement is subject to a federal law, which states payment will be the highest of three rates:
1) Medicare: #AlwaysTheLowest
2) Usual and Customary (U&C): the highest
3) Negotiated Amount: self-explanatory
TAKE HOME POINT: U&C is defined, federally, as the average of the CHARGED amount by physicians in that specific geographic region.
Sidebar: What your doctor charges doesn’t matter unless they are contracted and in-network. They can charge 1K or 100K…if your service is contracted at $900 bucks…the rest is a write-off…no one gets paid. THIS IS HUGE PAY ATTENTION.
IN THE CURRENT 2022 PRICE TRANSPARENCY LAW THEY CIRCUMVENT THIS RULE THE INSURANCE COMPANIES screw US ALL!!!
Let me explain…
https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf <— Here is the law. Read it. Press Ctrl+F and search the word “usual” and you’ll see.
Starting 01/01/2022, if a physician is OON and sees a patient and doesn’t have these BS forms signed, which “tell you what they charge” which doesn’t matter (because SEE ABOVE!!), then they can circumvent federal law.
Remember how U&C was the highest number of the 3 negotiation points? In the new legislation, U&C is casually and quietly redefined. It isn’t the CHARGE amount, it is what the IN-NETWORK providers are paid. The entire paradigm is flipped.
So if the TOP negotiation chip is now the bottom…OON reimbursement disappears…now every doctor needs to contract with insurance companies and accept their terrible rates to even get paid…boy, there goes OON payments and the biggest financial risk point for insurance companies.
Oh and also every single state has its own managed “arbitration process,” which has literally never existed before and will be grossly overcomplicated/poorly run because it is now a fractured system, to manage the negotiation process.
But don’t forget! This is all about “price transparency” and “protecting patients.” Bullsh*t. Go check your OON benefits on your plan. I’ll bet you they’re twice as bad as your IN benefits (e.g., 10K deductible and 50% coinsurance unless you have a stellar plan paid for by your employer). Reminder: Your OON benefits do NOT overlap with your IN. So you, the patient, gets stuck with the bill and the insurance companies now pay ZIPPO.
So, yeah, screw this rule and screw these guys. And if you’re a client and you want to get paid – have every patient sign this form set before every visit fully filled out with your price listed or else no one can get you paid.