High Value Health Care

PIRG urges swift enforcement of rules to give patients advance notice of charges for medical care

A new rule will give patients the right to get a reliable estimate of their costs when they are scheduling their care. But not everyone is happy about this requirement.

Health care

American flag under a stethoscope and pile of $100s
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Insured patients deserve to know what they'll have to pay for scheduled care - before they receive it.

Medical bills are confusing and patients often have no idea of what to expect for their financial costs for treatment, even when scheduled in advance. New requirements will change all that, allowing insured patients to have a written estimate of what their planned care will cost.

But hospitals and doctors oppose enforcement of this provision which would require that patients receive advance notice of their cost obligations for scheduled medical care. Those rules are only in the early stages and we are pushing against any further delay of implementation and enforcement. 

PIRG filed comments due today with the Centers for Medicare and Medicaid services today (CMS) in response to a Request for Information (RFI). The RFI was issued to inform rulemaking for advanced explanation of benefits (AEOB) and good faith estimates (GFE) as required under the No Surprises Act which was enacted in December 2020 as part of the Consolidated Appropriations Act, 2021. 

The AEOB must include the patient’s share of the costs for each procedure or treatment expected for the scheduled health services. The AEOB would be generated by health plans and sent to patients one day after receiving the GFE from the provider. The provider creates the GFE for the plan using medical coding information for the planned care. Providers argue that the systems aren’t in place to share this information swiftly and effectively. 

PIRG pushed back on this specious argument, pointing out that the information flows back and forth when Explanation of Benefits and medical bills are generated after care is provided. Advance notice 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 else can we advocate for ourselves when there are billing errors or over-charges?” 

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