NEWS RELEASE: Patients need, deserve upfront cost estimates

WASHINGTON — The Centers for Medicare and Medicaid Services’ (CMS) public comment period ended Tuesday for proposed rules related to advanced explanations of benefits (AEOB) and good faith estimates (GFE). Ahead of the deadline, the consumer advocacy group U.S. PIRG filed comments, including this excerpt:

Patients deserve to know their cost of scheduled care in advance and should be able to rely on that AEOB to make appropriate financial decisions as it relates to their medical treatments. We urge you to swiftly move from this request for comments to formal rulemaking. Every month of delay in implementing AEOB rules is another month during which some patients will hesitate to seek care because of unknown costs, or will schedule care but then be overwhelmed by their financial obligations that they couldn’t anticipate. 

Medical bills are confusing and patients often have no idea of what to expect for their financial costs for treatment. However, some hospitals and doctors oppose enforcement of the provision which would require giving patients advance notice of their cost obligations for scheduled care. 

How would this work? Providers first must create a good faith estimate — determining the likely services and charges for the patient’s scheduled care. They send that to the patient’s insurer, who would then use this information to create the AEOB — a written summary of the expected charges — and show the patient’s share of the costs for each procedure or treatment based on their insurance coverage. The plan would send the AEOB to the patient so they can see their share of costs before they even receive the care. 

Providers argue that the systems aren’t in place to share this information swiftly and effectively. 

However, U.S. PIRG pushes back on this specious argument, pointing out that medical charges and prices already flow back and forth between providers and insurers to create the Explanation of Benefits and medical bills sent to patients after care is provided. Advance notice of estimates of charges simply requires the same information to be shared between the providers and the plans before a patient receives treatment.

“Patients need and deserve advance notice of their share of the costs — especially when we schedule care in advance,” said Patricia Kelmar, U.S. PIRG’s health care campaigns director. “And we need that information in a uniform format so we have a chance of understanding our costs. How can we advocate for ourselves if we can’t even recognize billing errors or over-charges?”  

U.S. PIRG submitted its comments in response to CMS’ Request for Information, designed to get public input as required under the No Surprises Act. This 2020 law lays out in broad terms that insured patients can get a written estimate of what their planned care will cost. But CMS is still working on the specifics of those rules, while consumers await implementation and enforcement.