TAMPA, Fla. — A recent regulation change on January 1, 2021, is working to put the power back into the patients' hands when it comes to hospital billing and transparency.
The Centers for Medicare and Medicaid, or CMS, now requires all U.S. hospitals to create a comprehensive machine-readable file with all items of service and display shoppable services in a consumer-friendly format.
That's a tool and wealth of information Susan Potier wishes she knew about. A hospital trip in March of 2020 now has her questioning how she is going to pay tens of thousands of dollars back in medical bills.
"I woke up at like 5:30, 6:00 a.m. and I was asleep and I felt this pain running through my chest and my arm and I have never had anything like that before," Potier said.
A rush to the hospital led to a number of tests and a diagnosis of a possible stroke or heart attack.
She was sent home the same night and along with tens of thousands of dollars in medical bills that would come soon after.
"With the insurance, I think I racked up probably I would say maybe $75,000 to $90,000," Potier said.
CMS and the non-profit organization, Patient Rights Advocate.org want to help people like Potier and put the pricing power back in the hands of the patient.
Cynthia Fisher is the founder of the non-profit and has taken the fight to court and won.
"Patients have been blind to no prices before we get care. Blindsided by sometimes outrageously overcharged medical bills and then we're expected to pay with a blank check," Fisher said.
Fisher's organization was born during the Obama Administration.
"It puts consumers in the driver seat to drive down their cost of healthcare and win by not only protecting their health, but protecting their physical, mental, and financial health as well," Fisher said.
According to Patient Rights Advocate.org, of the 73 hospitals in the Tampa Bay area, 30 were not compliant.
Nine hospitals replied when asked about the discrepancy. They included Bayfront Health Brooksville, Baycare, Johns Hopkins All Children's Hospital, Lake City Medical Center, Blake Medical Center, Lakeland Regional Health, Encompass Health in Largo and Sarasota, Manatee Memorial Hospital and Advent Health.
CMS is the entity that conducts the audits to ensure hospitals are adhering to the new regulations. A spokesperson said as of April of 2021 they have begun sending warning letters to hospitals that are not abiding by the new rules.
"Upon receipt of a warning letter for noncompliance, hospitals have 90 days to address the findings cited in the warning letter. CMS will re-review upon expiration of the 90-day window, or earlier if a hospital alerts CMS that the finding(s) of noncompliance has been addressed. Based on re-review findings, the inquiry may be closed if the finding(s) is resolved, the hospital may be sent a second warning letter, or the hospital may be sent a request for a corrective action plan," CMS spokesperson.
If a hospital does not comply within the 90-day period they could be fined $300 a day.
For more information about the new regulations and to submit a discrepancy visit their website here.
List of Florida hospitals not in compliance with new regulations according to Patient Rights Advocate.org as well as responses from hospitals:
ARCADIA
- DeSoto Memorial Hospital
DeSoto Memorial Hospital is not compliant because the standard charges list, which is just the chargemaster, only contains the gross price. They have a price estimator tool.
BARTOW
- Bartow Regional Medical
Bartow Regional Medical Center is not compliant because patients are unable to access the standard charges list link. They have a price estimator tool.
BRADENTON
- Blake Medical Center
Blake Medical Center is not compliant because the list of the standard charges only includes CPT codes, the gross charge, and the undiscounted cash price. It is missing de-identified min/max as well as all negotiated rates. The price estimator tool does not allow the uninsured consumer to obtain an estimate at the time of use of tool.
Blake Medical Center response:
"The regulations require hospitals to post a shoppable, consumer-friendly list of services or a price estimator tool, and provide a machine-readable file containing five types of “standard charges.”
Our hospital websites have a consumer-friendly Patient Payment Estimator tool that provides relevant information to help patients understand what their out-of-pocket costs may be for hospital care.
In addition, we are using one of the machine-readable file formats listed in the regulations to provide the five types of “standard charges.” This includes contracted rates with insurers. We started with the less complex contracts and will continue to post information as our teams work through additional contracts."
- Lakewood Ranch Medical Center
Lakewood Ranch Medical Center is not compliant because the standard charges list obscures data for the de-identified min/max values as well as negotiated rates. The negotiated rates only include the major payors and not their respective plans (i.e Cigna, Aetna but no plan names). They have a price estimator tool.
- Manatee Memorial Hospital
Manatee Memorial Hospital is not compliant because the standard charges list obscures data for the de-identified min/max values as well as negotiated rates. The negotiated rates only list major payors and some specific plans but does not clearly associate both payor and plan with the negotiated rate for each item/service. They have a price estimator tool.
Manatee Memorial response:
"Manatee Memorial Hospital complies with the CMS pricing transparency rule that became effective January 1, 2021. The pricing information is expected to be helpful to consumers in making healthcare decisions."
Kevin DiLallo, CEO and Group Vice President Florida Region, UHS, Inc,:
“Manatee Memorial Hospital and Lakewood Ranch Medical Center are committed to price transparency and have both a Price Estimator Tool and a Standard Charges File posted on their websites, consistent with the federal rule. The standard charges file does not ‘obscure data’ for any service or item which is typically not separately reimbursable. Services and items not separately reimbursable are included and identified as “Packaged” where applicable, as permitted by the federal rule, to allow for the listing of all items with various reimbursement types. In accordance with the CMS regulatory guidance, we have made a good faith effort to present our negotiated rates in a consumer friendly format. As contracts are updated, we will continue to focus on transparency. We strongly encourage patients shopping for services to use our Shoppable Services Price Estimator tool, contact their health insurance provider, or call us to discuss estimates specific to amounts potentially owed, including deductibles, copayments, and coinsurance balances.”
BROOKSVILLE
- Bayfront Health Brooksville
Bayfront Health Brooksville is not compliant because the standard charges list only lists major payors and some specific plans, but does not clearly associate both payor and plan with each negotiated rate for each item/service. There are SVCCD codes but no CPT codes. They have a price estimator tool.
Bayfront Health response:
"Our hospital has done our best to ensure the information posted on our website conforms to the federal requirements. As required by the federal regulations, our payer-specific negotiated rates and the billing codes used by our hospital are posted in a single, machine-readable, digital format and we provide a self-service online payment estimator for patients' use. We feel the comprehensive information posted to our website aligns with this guidance.
In addition, because we know patients are most interested in understanding how much they will pay out of pocket for care, our patient access team is available to help them understand their health insurance benefits and provide a personalized estimate."
CLEARWATER
- Morton Plant Hospital
Morton Plant Hospital is not compliant because patients are unable to access the standard charges list link. They have a price estimator tool.
DUNEDIN
- Baycare Alliant Hospital
Baycare Alliant Hospital is not compliant because patients are unable to access the standard charges list link. They have a price estimator tool.
- Mease Dunedin Hospital
Mease Dunedin Hospital is not compliant because patients are unable to access the standard charges list link. They have a price estimator tool.
LAKE CITY
- Lake City Medical Center
Lake City Medical Center is not compliant because the standard charges list only includes the gross charge and undiscounted cash price. It is missing de-identified min/max as well as all negotiated rates. They have a price estimate tool that does not allow the uninsured consumer to obtain an estimate at the time of use of tool.
Lake City Medical Center response:
"The regulations require hospitals to post a shoppable, consumer-friendly list of services or a price estimator tool, and provide a machine-readable file containing five types of “standard charges.”
Our hospital websites have a consumer-friendly Patient Payment Estimator tool that provides relevant information to help patients understand what their out-of-pocket costs may be for hospital care.
In addition, we are using one of the machine-readable file formats listed in the regulations to provide the five types of “standard charges.” This includes contracted rates with insurers. We started with the less complex contracts and will continue to post information as our teams work through additional contracts."
LAKELAND
- Lakeland Regional Health Medical Center
Lakeland Regional Health Medical Center is not compliant because the standard charges list does not include any negotiated rates. They have a price estimator tool.
Lakeland Regional Health response:
"Lakeland Regional Health is committed to providing price transparency for our patients and families. The price estimator tool that is accessible on our website allows consumers to shop for a large number of hospital services to determine estimated out-of-pocket costs based on their specific health insurance plan benefits. We are fully aware of the CMS requirements that went into effect on January 1 of this year and have made good faith efforts to comply with CMS regulations and will continue to monitor and adjust price transparency disclosures as needed."
From Lance Green, CPA, Executive Vice President/Chief Financial Officer
LARGO
- Encompass Health Rehabilitation Hospital of Largo
Encompass Health Rehabilitation Hospital of Largo is not compliant because the standard charges list has obfuscated data elements with respect to negotiated rates, gross charges, and deidentified min/max. While payors and plans are listed, the prices are listed as NA for portions of data. They have a shoppable services list.
Encompass Health response:
"Encompass Health is dedicated to providing high quality, affordable care to our patients, and we support price transparency. The Encompass Health hospitals in Largo and Sarasota are in compliance with CMS regulations regarding hospital price transparency, and CMS has not indicated otherwise.
Each insurance plan only has one payment type. For example, each plan with a per diem payment methodology will show “N/A” for other payment lines on the file.
We cannot provide information related to Lakeland Health Regional Medical Center, as it is not part of Encompass Health."
PLANT CITY
- South Florida Baptist Hospital
South Florida Baptist Hospital is not compliant because patients are unable to access the standard charges list link. They have a price estimator tool.
SARASOTA
- Doctors Hospital of Sarasota
Doctors Hospital of Sarasota is not compliant because the standard charges list only includes CPT codes, the gross charge and undiscounted cash price. It is missing de-identified min/max as well as all negotiated rates. The price estimator tool does not allow the uninsured consumer to obtain an estimate at the time of use of tool. This is not compliant.
- Encompass Health Rehabilitation Hospital of Sarasota
Encompass Health Rehabilitation Hospital of Sarasota is not compliant because the standard charges list has obfuscated data elements with respect to negotiated rates. While payors and plans are listed, the prices are listed as NA for portions of data. They have a shoppable service list.
Encompass Health response:
"Encompass Health is dedicated to providing high quality, affordable care to our patients, and we support price transparency. The Encompass Health hospitals in Largo and Sarasota are in compliance with CMS regulations regarding hospital price transparency, and CMS has not indicated otherwise.
Each insurance plan only has one payment type. For example, each plan with a per diem payment methodology will show “N/A” for other payment lines on the file.
We cannot provide information related to Lakeland Health Regional Medical Center, as it is not part of Encompass Health."
ST. PETERSBURG
- Johns Hopkins All Children’s Hospital
Johns Hopkins All Children’s Hospital is nearly compliant. The standard charges list obscures data with respect to their gross charges, which they state is an “average” charge, as well as their negotiated rates. They have a price estimator tool.
Johns Hopkins All Children's Hospital response:
"Johns Hopkins Medicine recognizes the role transparency plays in helping our patients and guests understand our pricing, make informed decisions about care at one of our hospitals, and access financial assistance, if needed.
Ahead of the January 1, 2021 implementation of the federal price transparency requirements, we began work to set up a mechanism through which we could ensure compliance with the new law by providing a comprehensive, detailed list of hospital charges and negotiated fees, as well as estimates for at least 300 commonly performed hospital services. We also developed a care price estimate tool on our website, along with a tutorial and frequently asked questions to assist patients in determining the hospital expenses they can anticipate.
Johns Hopkins Medicine continues to work on additional initiatives that will provide education and assistance to ensure that patients and guests are able to estimate their true out of pocket costs for a given service, as well as to connect patients with financial counseling to ensure that they are aware of all avenues to access care including receiving financial assistance."
SUN CITY CENTER
- South Bay Hospital
South Bay Hospital is not compliant because the standard charges list only includes CPT codes, the gross charge and undiscounted cash price. It is missing de-identified min/max as well as all negotiated rates. The price estimator tool does not allow the uninsured consumer to obtain an estimate at the time of use of tool. This is not compliant.
TAMPA
- Tampa General Hospital
Tampa General Hospital is not compliant because the standard charges list obscures all negotiated rates. The gross charge, self-pay, and de-identified min/max is not listed for every item/service leading to a significant amount of missing data. They have a price estimate tool.
Tampa General Hospital has a Price Estimator Toolthat gives patients the ability to make informed decisions about the costs of their medical care.
- Advent Health Tampa
Advent Health Tampa is not compliant. The standard charges list includes descriptions, relevant codes, gross and discounted cash prices, de-identified min/max and negotiated rates with third-party payors and plans but does not include all rates for every item/service. The list is very unorganized. They have a price estimator tool.
- Advent Health Dade City -- NOT COMPLIANT
- Advent Health Connerton -- NOT COMPLIANT
- Advent Health Carrolwood -- NOT COMPLIANT
- Advent Health Heart of Florida -- NOT COMPLIANT
- Advent Health North Pinellas -- NOT COMPLIANT
- Advent Health Wauchula -- NOT COMPLIANT
- Advent Health Wesley Chapel -- NOT COMPLIANT
- Advent Health Zephyrhills -- NOT COMPLIANT
Link to all price estimate tools Advent Health system: www.adventhealth.com/price-estimator
TRINITY
- Medical Center of Trinity
Medical Center of Trinity is not compliant because the standard charges list only includes CPT codes, the gross charge and undiscounted cash price. It is missing de-identified min/max as well as all negotiated rates. They have a price estimator tool that does not allow the uninsured consumer to obtain an estimate at the time of use of tool.
VENICE
- Venice Regional Bayfront Health
Venice Regional Bayfront Health is not compliant because the standard charges list only lists major payors (i.e Cigna, BCBS, Aetna) and some specific plans with respect to Medicare Advantage, but does not clearly associate both payor and plan with all negotiated rates. They have a price estimator tool.
WINTER HAVEN
- Winter Haven Hospital
Winter Haven Hospital is not compliant because patients are unable to access the standard charges list link. They have a price estimator tool.
BayCare Health Response:
"BayCare has a long tradition of price transparency for shoppable services for our patients. For years we have provided estimates to patients for elected procedures and upon request for other services. Even ahead of the new federal rule, in 2019, we added the online MyEstimator pricing tool, so patients can get answers 24 hours a day.
The deficits you listed in regard to the new federal regulation refer to only one portion of the new rule. It has little to do with consumer information and is more about providing private business information to government and researchers via a “machine-readable file.” Compiling this file requires thousands of hours of efforts on providers’ part to comply and maintain in what has already been a challenging time due to COVID-19. BayCare is working to meet this requirement.
The good news for consumers, however, is they are already well served with the tools and services we already provide that deliver price estimates tailored to their specific insurance plan’s deductible, co-pays and other benefits."
