What You Need to Know about Price Transparency Regulations

BY KERRY ANN HAYON
PPRC DIRECTOR

Price transparency regulations that require physicians and hospitals to provide cost information for procedures and services to requesting patients has been in effect since January 1, 2014; however, there has lately been an increased focus from the media regarding this topic.

A recent Boston Globe article found overall awareness of the price transparency regulations and knowledge on handling patient requests for cost of services to be relatively low. Furthermore, conversation with physicians and practice managers reaffirm that cost information requests from patients is sparse.

Refining internal processes for handling these requests may be challenging, given the reportedly low volume of patient requests for cost information. It is important to make sure that your practice is ready to help in the event that a patient wants to know how much a service will cost. Here are the key points and considerations:

Requirements:

  • If asked, providers have two working days to disclose allowed amount, defined as the contractually agreed amount paid by a carrier to a health care provider, or charge of an admission, procedure, or service.
  • Providers must give patients or insurers any information — such as CPT codes — that their insurer needs to calculate what their out-of-pocket costs will be.
  • Providers who participate in insurance contracts must provide “sufficient” information about the proposed procedure or service to allow a patient to use the insurer’s toll-free telephone number/website established to disclose costs.

What Physicians Should Do:

  • Provide the patient with the CPT codes for all anticipated services and procedures. Patients will provide those codes to their health plan to obtain the contracted costs for the professional services, facility fees, and out-of-pocket costs related to the request.
  • Patients should also be given the phone number of the facility’s billing office, which may be able to provide additional information about facility costs.
  • Cooperate with health plans’ requests for further information in a timely fashion, to help the health plans make the most accurate estimates possible for your patients.
  • Create a documented process for handling patient requests, make sure your staff understand the requirements, and know how to handle patient requests for information.

Useful Resources:

Web resources located at www.massmed.org/prices contain additional helpful information including a link to a downloadable cost transparency worksheet that may be useful in providing the necessary information for patients to successfully obtain out-of-pocket cost from their health plans.

For additional questions, contact the PPRC Help Center at (781) 434-7702 or www.massmed.org/pprc.

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