The Centers for Medicare & Medicaid Services on Aug. 2 published its final inpatient prospective payment system, or IPPS, rule (see pages 2135-2142) for federal fiscal year 2019. The IPPS rule contains a transparency provision that will be effective Jan. 1, 2019.
The Affordable Care Act included a requirement for all hospitals to establish, update and make public a list of the hospital's "standard charges" for items and services provided by the hospital, including for Diagnosis Related Groups, DRGs. This information is to be made available each year.
CMS, in the 2015 final rule issued guidelines for how hospitals should comply with this requirement, including the following two options:
1.Make public a list of the hospital's "standard charges" (whether that is the chargemaster itself or in another form of its choice); or
2.Make public the hospital's policies for allowing the public to view those charges in response to an inquiry
In the 2015 rule, CMS indicated hospitals could satisfy the ACA requirement by posting information on the internet, but did not make that method a requirement, concluding that "hospitals are in the best position to determine the exact manner and method by which to make the list public..."
CMS also expected hospitals to update the information at least annually, or more frequently if warranted, to reflect current charges.
2019 FINAL IPPS RULE
In its proposed and final 2019 IPPS rules, CMS acknowledged Chargemaster data are "not helpful to patients for determining what they are likely to pay for a particular service or hospital stay."
However, in an effort to continue moving the needle on price transparency, the final rule requires hospitals to make available a list of their current "standard charges" via the internet in a machine-readable format, and to update it at least annually.
This requirement can be met in the form of the Chargemaster itself or another form of the hospital's choice, as long as it is in machine-readable format.
WHAT IS A CHARGEMASTER?
A Chargemaster is a comprehensive list of charges for each inpatient and outpatient service or item provided by a hospital - each test, exam, surgical procedure, room charge, etc. Given the many services provided by hospitals 24 hours a day, seven days a week, a Chargemaster contains thousands of services and related charges.
Chargemaster amounts are almost never billed to a patient or received as payment by a hospital. The Chargemaster amounts are billed to an insurance company, Medicare, or Medicaid, and those insurers then apply their contracted rates to the services that are billed. In situations where a patient does not have insurance, our hospital has financial assistance policies that apply discounts to the amounts charged. More information on our financial assistance policies can be found obtained by contacting the hospital financial services department.
Health insurance companies contract with hospitals to care for their customers. Hospitals are paid the insurance company's contract rate, which generally is significantly less than the amount listed on the Chargemaster. The insurance company's contract rate, not the Chargemaster, is the basis for determining the patient's actual out of pocket costs. As an example, a hospital may charge $1,000 for a particular service, while the insurer's contract rate may be $700. If the patient's insurance plan indicates the patient is responsible for 20 percent of the contract rate, the patient would owe $140 ($700 x 20 percent).
ARE CHARGES THE SAME FOR EVERY PATIENT?
The list of charges is the same for all patients. However, the total charges for an individual patient often vary from one patient to another for a number of reasons, including:
•How long it takes to perform the service or how long it takes you to recover in the hospital
•Whether the service or procedure you receive is more or less difficult than expected
•What kinds of medication you require
•Whether you experience complications and need additional treatment
•Other health conditions you may have that may affect your care
IS THE CHARGE THE SAME AS WHAT A PATIENT PAYS?
Chargemaster information is not particularly helpful for patients to estimate what health care services are going to cost them out of their own pocket.
The charge listed in the Chargemaster is generally not the amount a patient will pay. If you have health insurance, the amount you will be billed and expected to pay for your services depends on your specific health insurance coverage and your insurance company's contract with the hospital.
If you do not have health insurance, you may be eligible for reduced costs under the hospital's financial assistance policy, or you may be eligible for Medicaid coverage.
WHAT IS NOT INCLUDED IN THE CHARGEMASTER LIST?
The hospital's chargemaster does not include charges for services provided by the doctor (or doctors) who treat you while you are at the hospital. You may receive separate bills from the hospital and the doctors involved in your care.
Here is a partial list of health care providers who may bill you separately:
•Your personal doctor, if he/she sees you in the hospital
•The surgeon who performs your procedure
•The anesthesiologist who works with the surgeon
•The radiologist who reads your x-rays or other imaging
•Other doctors who may be consulted by your doctor during your time in the hospital
WHERE CAN I FIND MORE INFORMATION ABOUT HOSPITAL COSTS?
If you would like more information about the Chargemaster, what your care will cost you or the hospitals' financial assistance policy, please contact the hospital financial services department.
Please consult with your insurance provider to understand your insurance coverage, which charges will be covered, how much you will be billed, information on deductibles, and your expected out-of-pocket responsibility.