Since her brother died at 52 from colon cancer and her sister was diagnosed at 42, Lisa Gold has prioritized colonoscopies as part of her routine care.
Gold, a Long Beach, California, filmmaker and screenwriter, paid $132 in 2018 and $190 in 2019 with her Anthem Blue Cross insurance plan covering the bulk of the costs. But for a December 2020 procedure, done by the same Cedars Sinai-affiliated doctor at the same outpatient facility, she was billed more than 17 times as much.
“I thought it was a mistake,” Gold said of the $3,384 bill. She complained to her longtime gastroenterologist and received a small discount, but no explanation for the increase.
A federal law that went into effect last year is supposed to prevent surprise charges by hospitals and doctors like Gold experienced. Yet questions persist over how well agencies are administering it. While many hospitals say they fulfill the law’s requirements, some independent analyses – including one released this week – have concluded that fewer than 1 in 5 hospitals actually do.
Lax federal enforcement means hospitals feel little pressure to comply despite fines that could reach $5,500 a day, patient advocates say. And in cases where hospitals do make pricing information available to the public, the information can be incomplete or presented in formats that are nearly indecipherable to average consumers.
Designed to empower patients and hold down medical costs, the law requires hospitals post a searchable list of 300 medical services to allow consumers to shop and compare prices before receiving care. Hospitals also must post data files containing rates negotiated with health insurers for a broad list of procedures in a computer-readable format so the information can be analyzed.
The Centers for Medicare and Medicaid Services, which administers the law, defends its enforcement and said outside estimates on hospital compliance vary widely because they apply different methodologies. Hospitals dismiss the findings of some reports, saying they set higher standards than the federal agency.
Only two hospitals have been fined for failure to post prices, an indication that enforcement by the Centers for Medicare and Medicaid Services has been “lukewarm” and needs to get tougher, said Ge Bai, a Johns Hopkins University professor of accounting and health policy and management.
CMS is “not sending a strong signal to the market that they are taking this seriously,” said Bai, an expert on health-care pricing. “The hospitals are taking their cue from CMS. They are thinking, 'How likely is (CMS) going to pick me?'"
That leaves patients like Gold to navigate a complicated system on their own. She recently attempted to access pricing information from Cedars Sinai websites but was unable to easily find charges for a colonoscopy. A Cedars-Sinai representative said the hospital does have a price estimator, which requires a person input data such as name, date of birth and insurance member number.
Gold switched doctors in hopes of getting a better price next time she goes for a colonoscopy, but feels there's no guarantee. Given her family history, she said, what choice does she have?
“Colonoscopies prevent cancer," she said. "We don’t have another procedure that does that.”
Complaints trigger enforcement
CMS has not reported how many of the nation's 5,200-plus hospitals agency personnel have been reviewed so far.
As of late July, CMS issued 368 warnings to hospitals that they had not complied with price-transparency requirements. Regulators followed with another 188 corrective action plan requests; CMS staff cleared another 204 hospitals who fixed issues cited by regulators.
Hospitals that fail to correct their shortcomings can be fined every day they don't comply. Hospitals with 30 beds or more must pay $10 per bed per day up to a maximum daily fine of $5,500.
"We are encouraged by the significant increase in hospital compliance that we have witnessed since implementation of the regulations last year, and we are committed to working with hospitals through the enforcement process to continue to improve hospital compliance," CMS said in a statement.
In the two instances when CMS did resort to fining hospitals, it proved wholly effective, said Cynthia Fisher, founder of Patient Rights Advocate, a nonprofit that pushes for price transparency in health care.
In June, CMS assessed combined penalties of nearly $1.1 million to Northside Hospital Atlanta and Northside Hospital Cherokee in Canton, Georgia. Both hospitals quickly came into compliance after being fined and now have "exemplary" price disclosures, Fisher said.
"If (CMS) does its job and actually enforces this law, hospitals will come into compliance," Fisher said.
A review of 2,000 hospitals released this week by Fisher's group found 16% posted complete data files as well as a consumer-friendly searchable database. Most hospitals have posted data files with some fields of information missing, such as rates negotiated by individual insurers.
Those findings are in line with a study published in June in the Journal of the American Medical Association that found only 5.7% of hospitals had both the searchable databases and machine-readable data files required by the law. That study relied on data reported as of September.
The more recent Patient Rights Advocate report found 101 hospitals had not posted any data files. Furthermore, the report said two of of the three largest hospital systems in the United States – HCA Healthcare and Ascension – have not fully met requirements. The report said none of HCA's 186 hospitals fully complies, nor do any of Ascension's 85 hospitals.
Officials with both hospital chains dispute the findings.
In a statement, Ascension described itself as a leader in price transparency. The hospital chain cited a critique by the American Hospital Association, an industry group that represents nearly 5,000 hospitals, that said such third-party reports ignore aspects of CMS guidance on the rule. For example, when hospitals bundle services together and charge a single price, they might not fill out every single field in the detailed data files.
"CMS itself has indicated that only a small number of hospitals across the country are not in compliance," Ascension's statement said. "We will continue to find ways to make sure consumers and patients have the most current information available to make an informed healthcare decision."
Harlow Sumerford, HCA's director of media relations, said the Nashville hospital chain has complied with the federal law's requirements since January 2021.
The chain's hospital websites have a payment estimator tool that "provides relevant information to help patients understand what their out-of-pocket responsibility may be for hospital care, including those that are uninsured," Sumerford said in an email.
He added that hospitals have posted data files that contain rates with insurers in a format as required by federal regulations.
Fisher said she is confident in the accuracy of her group's report, which she said was validated by an outside firm. More importantly, she said comprehensive pricing data is pivotal to give consumers and others information they need before they get hit with a big bill.
“The truth is in the data," Fisher said. "Any consumer or technology developer will struggle to find and compare all actual prices by plans when looking at the majority of hospital pricing files."
A birth brings unexpected charges
Jeremy Randall Griner bought a Florida Blue health insurance plan with maternity coverage and studied his financial responsibility under the plan.
So when his daughter was born in June and the bills began trickling in for the two-day hospital stay, he thought he’d have to pay about $2,700 – his family plan’s deductible – before insurance coverage kicked in. Even though his insurance plan has covered over $23,000, the hospital bills continue to arrive.
It’s been a frustrating experience for Griner, who lives near Lakeland, Florida, an attorney who is familiar with insurance contracts and disputes. He has asked for line-item charges and discovered things he did not expect. One example: The family was billed $800 for the nursery even though his newborn girl was never there.
“Now I'm sitting here staring down $10,000 in out-of-pocket bills with a deductible of $2,700 and no one can really tell me why,” Griner said. “I like to think I'm a pretty sophisticated consumer being an attorney, but I feel like an idiot every time I talk to these people.”
Griner's story points out the challenge patients face when they try to navigate the health-care pricing system on their own, hospital-billing experts say. Even if they're aware of the pricing-transparency law, consumers lack the financial incentive to study the specifics if they believe their insurance plan will pay for the bill.
And that misses part of the point for the law's existence: keeping prices down for everyone, said Bai, of Johns Hopkins.
As Americans are increasingly being asked to pay a larger share of their medical bills through copayments and deductibles, which averaged $1,669 in 2020, even those with robust insurance plans have more incentive to check prices than they might think, the billing experts say.
Part of the problem is that what information is made available isn't done so with patients in mind, said Elisabeth Benjamin, vice president of health initiatives at the Community Service Society of New York and founder of We the Patients, an organization that highlights concerns about health care access, cost and quality.
CMS allowed hospitals to post the information in a format that was easier for them. The consumer-friendly database allows people to look up estimated prices for 300 medical services. The data files require a spreadsheet or other software to read and often include medical jargon or codes, making the information virtually useless to consumers.
"When the government put out all these price transparency rules, they didn't set up one standard, user-friendly, centralized website that everyone could go to and do apples-to-apples comparisons," Benjamin said. "Instead, we continue to indulge the health care industry with their demands of 'Oh, we want to do it our own way.'"
Benjamin said the law would be more useful for consumers if the federal agency compiled and posted the charges in a standardized way to the federal Healthcare.gov website or state insurance exchanges. That would allow consumers to get the data to shop for services or negotiate with hospitals or doctors over medical debt.
"It's almost useless for a patient," Benjamin said. "You're trusting providers that they're going to want to make this information transparent, when in fact, they do not."
Union targets high-cost hospitals
Greater price transparency for medical care holds great value for consumers or groups that are able to make sense of the information.
The New York City-based 32BJ Health Fund provides health insurance benefits for about 200,000 union employees and their families. In New York City, members include service workers such as doormen, concierge, security or maintenance workers.
This past year, the union negotiated the largest pay raise ever for its members in part because it anticipates $25 million in health care savings following a review of claims, said Cora Opsahl, the health fund's director.
That review concluded New York Presbyterian Hospital charged more than other New York City hospitals for medical care such as weight-loss operations, delivering babies or colonoscopies. The union health fund terminated the hospital from its network of providers effective this year.
While the health fund used its own members' claims to compare prices of New York hospitals, Opsahl said the health fund plans to use federal price transparency data going forward to compare what it pays for medical care to what other insurance plans have negotiated with hospitals.
"These transparency regulations will help bring to light a lot of the opaqueness that exists right now in hospital prices," Opsahl said.
Ken Alltucker is on Twitter at @kalltucker, or can be emailed at email@example.com.
This article originally appeared on USA TODAY: Are hospitals meeting requirement of medical billing transparency law?