As another layer of price transparency, In November of 2022, the Department of Health and Human Services (HHS) published the Hospital Owners Information dataset (the Dataset). The Dataset is aimed at making transparent the ownership structure of Medicare-certified hospitals.
No Surprises Act The lack of transparency that pervades the healthcare system exposes patients to problems such as surprise medical bills. The No Surprises Act (NSA) took effect in January 2022, establishing new federal protections against most surprise out-of-network medical bills. Surprise billing occurs when a patient receives out-of-network services during an emergency visit or from an out-of-network provider at an in-network hospital or other facility without advance notice and consent. The Act prohibits providers from billing patients more than the median in-network charge and allows providers to appeal disputes over coverage of surprise bills to a third party.
Advanced EOB For participants in an employer-sponsored health plan, healthcare consumerism brings an opportunity to improve engagement and understand their health plan. Today, plans regularly provide an explanation of benefits (EOB) which confirms any excluded charges, the covered charges, and how the covered charges will be shared between the participant and the plan.
The NSA provides for an “Advanced EOB.” In the future, participants will be able to gain a better estimate of the portion of any anticipated medical services that qualify for plan benefits, and what portion of those expenses will be paid by the participant. Participants will be able to request a Good Faith Estimate (GFE) from their medical providers. Then, the GFE can be submitted to the health plan administrator as part of a request for an Advanced EOB.
Transparency in coverage Going forward, innovators are likely to leverage the Advanced EOB process to compare the cost sharing for the submitted GFE in a side-by-side display and to bring attention to a quality provider charging lower costs. Beginning January 1, 2023, a new transparency rule took effect: Transparency in Coverage (TiC) requires insurers and plans to disclose negotiated rates for in and out-of-network rate history and drug pricing information. The goals are the same in terms of prompting consumerism – ensuring participants have access to the information necessary to incorporate financial criteria into their decisions regarding medical services.
The required provision of an online pricing tool should include personalized, real-time, cost estimates for covered services and items, including pharmacy. Paper versions must be available upon request. Initially, for plan years beginning on or after Jan 1, 2023, the online tool must provide cost estimates for 500 shoppable services. In the future, for plan years beginning on or after Jan. 1, 2024, the online tool must provide cost-share estimates for all covered services.
