Wondering how much your medical care will cost? New rules could help


To paraphrase Forrest Gump:

Medical bills are like a box of chocolates – you never know what you’re getting.

Only worse: They are not chocolates, but medical bills.

But it’s true: most people don’t know beforehand how much to pay for their medical care. Even if you check whether your insurance will cover the care you plan, it is not easy to get a specific estimate. It is very different from other services, such as B. the repair of your car or your house.

In many cases, caregivers or bill senders cannot tell you in advance what amount to expect. And questions have long been stigmatized. Since the price has never been easy to negotiate or buy, it may seem pointless to ask for it. After all, how can you price your health?

But with healthcare costs skyrocketing and medical bills ravaging personal and family finances, we should all demand more price transparency and the elimination of large, unexpected medical bills.

There is a new rule about transparency in the city

Despite celebrity cameos during this year’s Oscars advocate Hospital price transparency rule, relatively few people seem to know about it. From January 2021, hospitals must

  • make the standard prices for at least 300 plannable medical services publicly available, such as B. Visits to the doctor, x-rays and laboratory examinations
  • Offer negotiated prices with insurance companies for these services and the lowest accepted price for self-payers
  • Provide clear and understandable information about what is included in the advertised price, including doctor, hospital and pharmacy fees.

Let’s say you’re planning medical care at a nearby hospital – maybe see your doctor, get a knee replacement or a mammogram. In theory, you should be able to look up the price and compare the cost to similar services from other providers.

In practice, prices vary widely based on geographic location, insurer, and the specific type of plan, as well as the hospital. For example, the cost listed by a well-known healthcare system for an MRI of the knee in three of its hospitals ranged from $ 1,650 to $ 2,500; an MRI of the head ranged from $ 1,700 to nearly $ 3,400.

No surprises?

A separate rule that No surprise law, comes into force in January 2022. The law applies to all types of healthcare facilities, not just hospitals. It’s designed to avoid surprise medical bills related to off-network care. For example, if you are operated on by a surgeon in your insurance network, you might get a hefty bill from the anesthetist who was not on your network – although you couldn’t know in advance.

These surprise bills are common. Corresponding an analysis, 22% of emergency rooms in the United States result in unexpected medical bills related to healthcare provider network involvement.

The new rule

  • requires emergency care within the network without the prior consent of your health insurance company. This means that you will be billed for what you would have if the provider were on your health network – even if your health plan considered them non-network-based.
  • limits fees such as deductibles or co-insurance to on-grid amounts for emergency care or care in an on-grid facility (this also applies if some of your healthcare providers are off-grid).
  • Prohibits additional charges for certain off-grid treatments received at a health location within your plan’s network – such as anesthesia given to you by an off-grid anesthetist in an on-grid health facility.
  • prohibits other charges outside the network, such as B. Consultations with specialists or diagnostic tests, without prior notice and consent.

Will these new rules work?

While these new rules are important steps in the right direction, they encounter serious obstacles before they can function as intended.

The hospital price transparency rule:

  • Applies to hospital care only. The treatment you will receive at your doctor’s office is not covered.
  • Depends on hospital compliance. A study conducted shortly after the rule came into effect found that only about a third of the hospitals provided the necessary information.
  • Doesn’t prevent hospitals from posting confusing or unhelpful pricing information. I have surely noticed that by examining several hospital systems. One hospital estimated the cost of a chest x-ray to be between $ 10 and $ 675, depending on the insurance plan. Another asked me to provide information that most people cannot provide, such as: B. Choose from dozens of CT scan options.
  • Does not establish a consistent format for publishing price information. In order to calculate the costs for basic services as well, you need information about your health insurance plan, because Hospitals often negotiate different prices depending on the health insurance companies and their various plans. No standard data file format is required – such as Excel spreadsheets – and you may need to know billing codes to move forward.
  • Does not include a way to compare quality. Sure, you could shop around to find the lowest price, but the quality of maintenance may be lower on some – if not all – cheaper websites. You can review a limited amount of quality information. Care comparison for people using Medicare is an example. But it doesn’t cover all due diligence, it is unclear how reliable it is, and specific information is often difficult to find and understand.

The No Surprises Act:

  • Can be difficult to enforce. When it goes into effect in January 2022, collecting details of each person’s health insurance coverage will become complicated and may be inaccurate. Health insurances differ, for example, in what they cover, how much of the costs are covered and whether there is a deductible or a co-payment. Your doctor’s office may not be able to correctly estimate your share of the bill.
  • Might have little impact. Hospitals and health care providers can ask people to waive their rights to the protection of the regulation, agree to a higher rate of visits to a specific doctor, or be able to visit a health care provider more quickly.
  • Can be costly to healthcare facilities and doctor’s offices. Ultimately, this could undermine its usefulness.

What is important is that these new rules do not help directly lower the cost of our health care. One hope is that fixing upfront prices could lead to competition that could drive prices down.

The bottom line

I welcome the efforts to improve price transparency in medical care and to prevent unexpected bills. The price of health care clearly matters to anyone who is expected to be paid for it. Perhaps the indignation will increase over the lack of clarity in the accounting and the wide and amazing price differences stimulate more effective measures for change. And some may find that a new way to compare prices and choose the cheapest option allows them to get the medical care they need instead of putting it off. It is clear that making costs more predictable is a worthwhile goal.

But the devil is in the details. And we still have a long way to go before we figure out how to control healthcare costs.

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