Understanding a Hospital Chargemaster
Consumers are seeking more information from hospitals about
the cost of their care and the quality of that care so they can make informed
decisions. They also need a similar commitment from insurers, physicians, and
other providers. With all parties working together, consumers
can navigate the complex care system, armed with sufficient information to
make the best choices about their health care.
Surprise Balance Billing
Surprise medical bills may occur when a patient receives care from an out-of-network provider or when his or her health plan fails to pay for covered services provided at an in-network facility.
As part of the Bipartisan-Bicameral Omnibus COVID Relief Deal signed into law December 21, 2020, Congress passed another round of coronavirus relief funding including the “No Surprises Act.” This new law protects patients—starting during 2022—from unexpected medical bills by prohibiting providers from balance billing patients for out-of-network emergency services or non-emergent care at an in-network hospital that patients would not know is being provided by an out-of-network physician or laboratory.
The bill also provides a framework governing payment disputes between providers and insurers, which will be finalized through rulemaking by the secretaries of the U.S. Departments of Health and Human Services, Labor, and Treasury during calendar year 2022. Specifically:
- Insurers and providers will have 30 days to negotiate payment of out-of-network bills
- If the parties are unable to reach an agreement, they may access a binding Independent Dispute Resolution (IDR) process, administered by independent entities, in which one offer prevails
- The IDR entity is required to consider the market-based median in-network rate, alongside other relevant information brought by either party
- Billed charges and public payor rates (e.g. Medicare and Medicaid) are excluded from consideration
This federal solution largely aligns with the position of HAP and the American Hospital Association (AHA) that consumers must be protected from surprise bills, but that hospitals and payors should be left to negotiate reimbursement without government interference. The act also calls for an efficient process for resolving payment disputes, and other details about payment dispute arbitration and resolution. HAP is working with the AHA to influence federal rulemaking and ensure that consumers and hospitals are prepared to implement these requirements during 2022.
Publishing Standard Charges and Negotiated Rates
Effective January 1, 2021, hospitals were required to:
- Post online a list of five specific types of “standard” charges, including payor-specific negotiated rates, for all items and services in a machine-readable format updated at least annually
- Post payor-specific negotiated rates for all items and services, and also publish the negotiated rates for 300 "shoppable" services (those that are scheduled in advance of treatment), including 70 defined by the Centers for Medicare & Medicaid Services
Posting standard charges and negotiated rates can make available more information about what the insurer pays the provider, but it does not tell consumers what they will pay out-of-pocket for an item or service. While there are standard charges, there is no standard patient or treatment, and the lowest number doesn’t tell the whole story.
Patients are strongly urged to speak directly with their physicians to determine the appropriate course of clinical care, and to then immediately follow up with their insurers, and hospitals to get detailed information about the cost of their individual care. Many hospitals have online price calculator tools to help patients estimate potential costs, and all hospitals have billing professionals who can assist patients with individual circumstances and specific out-of-pocket expenses with or without health insurance.