Both hospitals and employers received a reprieve from a quickly approaching deadline that will “eventually reshape financial management of the health care industry.” HHS quietly released the revised guidelines on August 20, 2021, that requires health plans (employers), health care providers (health systems), and pharmaceutical manufacturers more flexibility in implementing surprise billing and price transparency rules.

In making the change, HHS said the rule change was extensive, and it could not meet the pending deadlines to issue compliance guidelines in time for the January 1, 2022, implementation date. The new implementation date for many rule segments is now July 1, 2022; other sections of the rule changes are still to be determined. 

The New Rules Don’t Just Impact Hospitals; Insurers Also Have Significant Obligations

According to Forbes, health insurers must provide personalized information about out-of-pocket costs via online, self-service tools. As part of the change, insurers need to include details about underlying negotiated rates paid to providers and historical information on out-of-network charges for procedures. 

Other specifics, according to the Society for Human Resources Management (SHRM), include:

– Drug Cost Reporting: Under the legislation passed in the Consolidated Appropriations Act (CAA), employer plans are to report very detailed prescription drug cost information to the agencies. This includes the 50 most covered drugs per plan, the 50 most expensive drugs per plan, and the total health spending for each plan broken out into specific categories. It’s anticipated that this data will still need to be reported for plan years 2021 and 2022, but not until year-end 2022.

– Gag Clauses: Under the CAA, plans cannot enter into network or other agreements that would prevent them from making available provider-specific cost or quality-of-care information to providers or participants. This includes electronically accessing de-identified claims and encounter information for each participant (consistent with privacy laws) or sharing either of those types of information with business associates. 

– Continuity of Care: Under the No Surprises Act, when a provider or network contract is terminated, plans must take steps to protect hospitalized or other continuing care patients. This requirement will take effect on January 1, 2022. The guidance clarifies that the agencies intend to issue formal regulations on this requirement but will not do so before the effective date. Until such rules take effect, plans will be held to a good-faith compliance standard.

Hospitals Take Notice: Consumers Want Price Transparency

The initial phase of the Hospital Transparency Rule went into effect January 1, 2021 – but hospitals have struggled to comply. A patient’s advocacy rights organization found that 94% of hospitals were non-compliant as of July. Another survey conducted earlier this year found that 83% of consumers wanted to see out-of-pocket costs estimated before receiving services. Some 25% of the respondents also said they would avoid healthcare without such information.  

These findings are similar to survey results in the 2021 Patientco State of the Patient Financial Experience. Among the Patientco findings:

– Concerns about out-of-pocket costs are the #1 reason patients skip or delay recommended healthcare treatment.  Nearly one in three patients have avoided care because they were worried about what they owe. A third of respondents said they had never received a cost estimate before recommended treatment. 

– Some 80% said they would follow through on care with flexible payment options. But less than half of patients understand conventional hospital mailed EOB statements. And hospital bills are one of the first obligations patients will not pay if they encounter financial hardship.

– About a third of patients would switch providers for more affordable payments options (2019 survey report).  And 82% of providers say they know more affordable payment options are a competitive advantage.

Regardless of the deadline for new healthcare rules, health systems can make the transition as a competitive advantage in deploying an AI digital platform. Learn more how Patientco – now part of Waystar – has helped dozens of health systems to make this transition.