But insurers are complying under the Transparency in Coverage regulations and that is where discrepancies in the disclosure of prices to the public have been found
Despite federal regulations requiring hospitals to publicly post their prices in advance of patient services, some large health systems still do not follow the law. That’s according to a new Transparency in Coverage Report from PatientRightsAdvocate.org (PRA), which found that some hospitals are “flouting” the federal Hospital Price Transparency Rule.
By cross-referencing price disclosures by hospitals and insurance companies, which are required to publish the amounts they pay for hospital services under federal Transparency in Coverage regulations, PRA, a 501(c)(3) nonprofit, nonpartisan organization, discovered the healthcare providers’ noncompliance with federal transparency regulation.
“Prices revealed in newly released health insurance company data files show some major American hospitals are omitting prices from their required price disclosures in violation of the federal hospital price transparency rule,” according to the PRA report.
Hospitals conceal their prices because they don’t want people to know how much rates for the same procedure vary,” Sally C. Pipes (above), President and CEO of Pacific Research Institute, wrote in the Washington Examiner. “A lack of price transparency benefits hospitals but not patients or payers. The federal government should not let providers get away with flouting the law,” she added. Clinical laboratories are also required under federal law to publish their prices. (Photo copyright: The Heartland Institute.)
Prices Paid by Insurers Missing in Hospital Files
PRA analysts compared publicly available Standard Charge File (SCF) data from seven Ascension Health and HCA Healthcare hospitals in Texas and Florida, and Transparency in Coverage disclosures from Blue Cross Blue Shield, Cigna, and UnitedHealthcare.
“PatientRightsAdvocate.org discovered several instances in which prices were omitted from the hospital files but appeared in the insurance company files,” noted the PRA report. “These discrepancies indicate that some large hospitals are not posting their complete price lists as required by the hospital price transparency rule.”
The federal Centers for Medicare and Medicaid Services (CMS) says hospitals must post standard charges in a single machine-readable digital file, and display in a consumer-friendly way, “300 shoppable services with discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges.”
But according to the PRA report and news release, the study team discovered that this was not always the case. Below are examples from the report of some of the discrepancies between prices on a hospital’s website and what payers’ websites showed as prices involving those same hospitals:
Ascension Seton Medical Center, Austin, Texas:
- The hospital SCF for shoppable services showed “N/A” (not available).
- UnitedHealthcare files included 16 rates it negotiated by plan and BCBS shared 12 prices by plan.
Ascension St. Vincent’s Clay County Hospital, Middleburg, Florida:
- The hospital’s SCF “did not contain negotiated rates” for services by Current Procedural Terminology (CPT) codes.
- UnitedHealthcare showed negotiated rates for 69 CPT codes.
HCA Florida Northside Hospital, St. Petersburg, Florida:
- PRA analysts found in the hospital SCF file “a range of 300 codes” and “one single negotiated rate.”
- The insurer, meanwhile, displayed “many different rates corresponding to 300+ codes in the range.”
HCA Houston Healthcare Clear Lake, Webster, Texas:
- The provider displayed for a BCBS HMO plan “seven distinct prices for 68 Medicare Severity Diagnosis Related Groups” (MS-DRGs).
- The BCBS HMO had 719 distinct prices for the codes in its disclosure.
HCA Medical City, Fort Worth, Texas:
- The provider displayed in its SCF “one distinct dollar price for all 62 MS-DRG codes that appeared as a group.”
- BCBS of Texas Blue Premier plan displayed 58 distinct negotiated rates for the codes in that group.
The report also summarized findings for:
PRA’s report casts light on inconsistencies between what insurers and providers share with the public on prices.
“Today’s report confirms that hospitals are hiding prices from patients and [this] calls into question their public assertions that individual prices don’t exist for many of the services they provide,” said PRA Founder and Chairman Cynthia Fisher in the news release.
“The data made possible by the [federal] Transparency in Coverage (TiC) rule reveals prices negotiated with insurers that hospitals did not disclose in the machine-readable files required by law. Our report is just the tip of the iceberg of what the staggering amount of data in TiC disclosures will reveal,” she added.
Ascension, HCA Note Compliance with CMS Rule
For its part, Ascension, in a statement to Healthcare Dive, confirmed it is complying with the CMS rule and offers consumers tools to estimate costs.
“We’re proud to be a leader in price transparency,” Ascension said.
HCA told Healthcare Dive it has “implemented federal transparency requirements in January 2021 and provides a patient payment estimator in addition to posting third-party contracted rates.”
Advice for Clinical Laboratories Sharing Test Prices
Hospitals flouting the federal transparency rule is not new. Dark Daily has covered other similar incidences.
In “Two Georgia Hospitals First to Be Fined by CMS for Failure to Comply with Hospital Price Transparency Law,” we reported how CMS had issued its first penalties to two hospitals located in Georgia for violating the law by not updating their websites or replying to the agency’s warning letters.
And in “Wall Street Journal Investigation Finds Computer Code on Hospitals’ Websites That Prevents Prices from Being Shown by Internet Search Engines, Circumventing Federal Price Transparency Laws,” we covered the Wall Street Journal’s report on “hundreds of hospitals” that had “embed code in their websites that prevented Alphabet Inc.’s Google and other search engines from displaying pages with the price lists.”
Clinical laboratory leaders who oversee multiple labs in healthcare systems may benefit from advice about CMS rule compliance shared in HealthLeaders.
- Post a separate file for each provider.
- Be “cognizant” of different sets of standard charges for multiple hospitals under one license.
“Today’s healthcare consumer wants to know prices in advance of service. That’s because many have high deductible health insurance plans of, say, $5,000 for an individual or $10,000 for a family as the annual deductible,” said Robert Michel, Editor-in-Chief of Dark Daily and its sister publication The Dark Report.
Clinical laboratory tests may not be the most expensive healthcare service. But they are critical for high-quality hospital care and outcomes. Increasingly, patients want to know in advance how much they will cost. This is true of patients of all generations, from Baby Boomers to Generations X, Y, and Z.
—Donna Marie Pocius