Physicians, patients, and employers have long wondered whether they’re getting a fair shake from health insurers, whose prices have been clouded in secrecy – until now.
After a months-long delay, a provision of the Affordable Care Act that recently took effect requires most health insurers and self-insured employers to disclose their payments to hospitals, physicians, and other health care professionals.
Carrie De Moor, MD, an emergency physician in Frisco and a member of the Texas Medical Association’s Council on Socioeconomics, characterizes the new regulation as a game changer.
“If it were to do what it’s meant to do, we would have really lifted the curtain that insurers have been hiding behind in terms of their contracting and really see the truth of in-network rates,” she said.
To comply, health insurers must post machine-readable files containing:
- Their in-network rates to hospitals, physicians, and other health care professionals for all covered items and services;
- Their allowed prices for, and billed charges from, out-of-network hospitals, physicians, and other health care professionals.
But questions remain about the efficacy of this new requirement, including whether health insurers will comply and whether patients will be able to access the price transparency data.
For instance, a similar policy took effect in January 2021, mandating hospitals “provide clear, accessible pricing information online about their items and services they provide,” according to the Centers for Medicare & Medicaid Services (CMS). But a July 2021 report by the nonprofit Patient Rights Advocate found just 14.3% of 1,000 hospitals reviewed had done so.
Compliance among health insurers may be higher thanks to stricter enforcement measures, including fines of up to $100 per day for each violation and for each patient affected, according to CMS. Texas’ three largest health insurers – BlueCross and BlueShield of Texas, UnitedHealthcare, and Humana – have posted the required data.
Still, Dr. De Moor points out that the machine-readable files are enormous and require significant time, hardware storage space, and third-party involvement to download and parse the data for patient use. She adds that physicians will have to advocate for stricter enforcement and more usable files to reap the benefits, including more leverage when negotiating with insurers.
“The problem is, it’s completely not transparent the way they’re posting stuff, and it’s completely not accessible,” she said.
The next phase of the policy, set to take effect in 2023, requires health insurers to develop an internet-based price comparison tool that estimates a patient’s cost-sharing responsibility for a specific item or service – from a list of 500 – from a specific hospital, physician, or health care professional, according to CMS.
Dr. De Moor believes such a tool is critical to the regulation’s success.
“Somebody who’s not in health care administration should be able to look at [this data] and say, ‘Okay, this makes sense,’” she said.