Need medical treatment this year and want to reduce out-of-pocket costs before you walk into the doctor’s office? There’s a new tool for that, at least for insured patients.
As of January 1, health insurance companies and employers that offer health plans must make available online calculators for patients to estimate in detail how much they will owe — taking into account deductibles and copays — for many types of services and drugs.
It is the latest effort in an ongoing movement to make it possible to compare prices and upfront costs in a business known for its lack of transparency.
Insurers must provide cost information for 500 non-emergency services that are considered “affordable,” meaning patients often have time to consider their options. Federal request originates from Transparency in insurance rules completed in 2020.
So how will it work?
Patients, when they know they need a specific treatment, drug or medical service, first log into the cost estimator on a website offered through their insurance company or their employer for some. Next, they can search for the care they need using a billing code that many patients may not have; or by a generic description, such as “knee repair” or “abdominal MRI”. They can also enter the hospital or doctor’s name or the dosage of a drug for which they are looking for pricing information.
Not all drugs or services will be available during the first year of implementing the tools, but list of 500 required items Covers a wide range of medical services, from acne surgery to X-rays.
Once the information is entered, the computer generates real-time estimates of the patient’s out-of-pocket costs.
Starting in 2024, the requirement for insurance companies expands to cover all drugs and services.
These estimator requirements are in addition to other pricing disclosures that have been in effect in the past two years, requiring hospitals and insurers to public price listingincluding those negotiated between them, along with costs for cash-paying patients or uninsured patients.
However, some hospitals are still not fully compliant with this 2021 publicity directive, and the data the insurer released in July was so large that even the researchers couldn’t find it. find it cumbersome for download and analysis.
Price estimators can help fill that gap.
New, personalized estimates calculate the annual deductible the patient still owes and the out-of-pocket limit that applies to their coverage. The amount the insurance company will pay if the service is out of network must also be shown. Patients can request information on paper, if they wish online.
Insurers or employers that fail to provide this tool could be fined as little as $100 a day for each person affected, a substantial incentive to comply — if enforced.
And there are caveats: Consumers using these tools must be enrolled in the respective health plan, and there’s no guarantee the final cost will be exactly as shown.
That’s because “unforeseen factors in the treatment process, which may involve additional services or providers, may result in a higher actual cost-sharing liability,” the federal regulators wrote in the outline of the rules.
Insurance companies will not be liable for inaccurate estimates.
Since the cost estimate may differ from the final price, either because the process is more complicated than originally planned or handled by another supplier at the last minute, a risk is “I could get bill for $4,000 and I’m going to be upset because you told me $3,000,” said Gerard AndersonProfessor of international health and health policy and management at the Bloomberg School of Public Health at Johns Hopkins University.
Many insurance companies have offered versions of cost estimators in the past, but a small percentage of enrollees actually use them, Studies have shown.
Federal regulators defended the requirement for estimators, writing that although many insurers already offer them, the new rule sets out specific parameters, which may be more detailed than those available. previous edition.
In sketching the final ruleThe Centers for Medicare & Medicaid Services pointed out that some calculators previously “on the market provide only broad range estimates or average price estimates using historical claims data,” and not always. includes information on how much the patient has accrued for an annual deductible or out-of-pocket limit.
The agency said such price disclosures would help people compare shopping and could ultimately help slow medical costs.
But that’s not a given.
“Many people believe CMS will make a significant impact, but they also have a long time frame,” said David Brueggemancommercial medical director at the consulting firm Guidehouse.
In the short term, results may be harder to see.
“Most patients do not travel mass to use these tools,” said Dr. Ateev Mehrotraprofessor of health care policy at Harvard Medical School.
There are many reasons, he said, including little financial incentive if they face the same dollar copay whether they go to a very expensive facility or a less expensive one. A better way to get patients to switch to lower-cost providers, he said, is to create rates that reward patients who seek out the most cost-effective providers for similar amounts. lower payment.
Mehrotra is skeptical that cost estimators alone will bring down rising medical prices. He is more than hopeful that, over time, requiring hospitals and insurance companies to list all of their negotiated rates will go further to reduce costs by recommending better providers. the most expensive tier, along with the insurance companies that negotiate the best rates.
However, cost estimators can be useful given the growing number of people on high deductible health plans who pay most of their health care out-of-pocket. them before they reach that deduction. During that time period, some can make significant savings by shopping around.
Brueggeman, at Guidehouse, said those deductions add “pressure on consumers to shop by price”. “Whether they actually do that is up for debate.”
