Committee Expands Inquiry into Hospital Billing SystemsInvestigation turns to overly complex invoices
WASHINGTON - The House Energy and Commerce Committee has opened a
new phase in its investigation of America's hospitals, seeking to assess the
full impact on consumers of payment disparities for services and to determine
whether hospital bills require an accountant to decipher.
Today the committee asked 10 leading American hospital companies to provide
extensive records on these and other topics. The health care providers contacted
are: Ascension Health, Inc. of St. Louis; Adventist Health of Roseville, CA;
Catholic Health East of Newton Square, Pa.; Sutter Health of Sacramento, Calif.;
New York-Presbyterian Healthcare System at Columbia Presbyterian Medical Center
in New York City; HCA of Nashville, Tenn.; Catholic Health Initiatives of
Denver; Mayo Health System of Rochester, Minn.; Tenet Healthcare Corp. of Santa
Barbara, Calif.; and Catholic Healthcare West of San Francisco.
The request follows a hearing by the Subcommittee on Oversight and
Investigations last year. At that hearing, witnesses spoke of hospitals
expecting patients without traditional health coverage to pay far more than the
amount that insurance companies paid for the same service. Those affected
include the millions of Americans without insurance and those that opt for
health savings accounts.
"When Americans go to the hospital, they shouldn't be taken to the
cleaners," said U.S. Rep. Joe Barton, R-Texas, chairman of the committee. "Today,
some patients are confronted with prices that can be grossly out of line and
with statements that might as well be in a foreign language.
"I want consumers to be empowered with the information they expect and
ought to have. They also deserve a pricing structure that is fair," he said.
"We need to know how close we are to those goals and to determine what, if
any, changes may be necessary to protect consumers. It is my hope that this
inquiry can help more Americans have access to affordable, quality health care."
Full text of the letter is below:
Dear _______:
Over the past two years, the Committee on Energy and Commerce has been
conducting an in-depth review of hospital billing and collection practices. On
June 24, 2004, we held a hearing on the impact of these policies and practices
on uninsured/self-pay patients. We are following up with the hospital industry
on several additional related matters raised in the course of our review that
also potentially affect issues of public health and consumer protection. -- more
--
The Committee's work to date has focused on hospital billing and
collection practices for uninsured/self-pay patients. The Committee examined how
hospitals often expect uninsured/self-pay patients to pay far more for their
care than what the hospitals would otherwise accept from managed care or
government programs and then sometimes aggressively pursue these patients for
this debt. Many hospitals have revisited their policies and practices on these
issues and recently, on February 10, 2005, the Committee sent a letter to the
nation's five largest hospital systems to learn how any such changes have
improved the situation of this patient population.
"We now follow up on two additional specific issues raised by these
earlier matters. First, while our inquiry to date has looked closely at the
manner in which hospitals set their charges, we turn now to the manner in which
those charges are presented, explained, and understood by the medical consumer
through patient billing records. The Committee is examining how clear, accurate,
and accessible these important documents are to patients. While this issue may
touch all medical consumers, it is perhaps most relevant to patients who handle
a bill without the direct support of a large and experienced health insurer -
such as the uninsured or a person managing a health savings account. Second,
expanding on the Committee's work that revealed how expensive hospital charge
master or "list" prices are, we are also studying further how patients and
other consumers may be directly or indirectly affected by these high prices.
Patient Billing Records
On December 17, 2003, new American Hospital Association guidelines for
treatment of uninsured patients in billing and collections matters included the
following: "Hospitals should use a billing process that is clear, concise,
correct and patient friendly." Many patients, however, may still find medical
bills to be very difficult to understand and evaluate. To be sure, medical
providers necessarily use terminology outside the common experience of most
patients; nevertheless, health care consumers must be given every opportunity to
understand exactly what they are paying for and how much they are paying -
particularly given the significant costs and financial consequences involved.
Transparency and accuracy in patient billing records are vital to enlisting
patients and consumers in monitoring and controlling health care costs.
What is the Impact of "Charge Masters" on Consumers?
The Committee has closely studied the impact high hospital charge master
prices have on uninsured/self-pay patients. In its defense, some in the hospital
industry have suggested that few parties, including many uninsured patients, in
actuality, pay these full rates. However, given the magnitude of these prices,
the Committee must examine further the significance of these charges to patients
and consumers. As such, the Committee will explore two areas where these high
charge master rates may impact, directly or indirectly, patients and consumers.
1. Out-of-Network Patients: Out-of-network patients are insured
individuals treated, by circumstance or choice, in hospitals with whom their
health insurer has not negotiated any rate or discount. While the insurer may
cover part of the services, hospitals may seek the balance of the bill (the
difference between what the health insurer pays and the charge master price)
directly from the patient. This "balance billing" may be surprising insured
patients with unexpectedly high bills based on charge master rates.
2. Property/Casualty Insurers: The Committee is also exploring how
hospital charge master rates impact consumers in the area of property/casualty
insurance, such as automobile coverage. Property/casualty insurers may be paying
medical benefits under their policies at or close to the full charge master
rates. Unlike health insurers who can negotiate discounts in advance with an
area hospital, car insurers cannot know where their insured will be when
involved in an accident and have to pay after-the-fact charges - sometimes at
full charge master rates. This may mean insureds pay hospital charge master
rates indirectly in their auto premiums and see their policy limits quickly
exhausted. We will look at whether these entities, and their insureds, are
shouldering the full charge master rates.
Record and Information Requests
Pursuant to Rules X and XI of the U.S. House of Representatives, please
provide the Committee with the following records and information by May 13,
2005. Please note that Requests Nos. 2, 3, 5, 6, 8, 10, 11, 13, 14, 15, 16, 17,
18, 19, and 21 ask for narrative responses or a statement of specific data. With
respect to these specific Requests, answers by way of simple reference to
produced documents will be insufficient and incomplete. The breadth and
timeliness of this review requires each respondent to prepare and submit
complete written responses to these Requests, as appropriate. Next, where your
response to this letter will include documents which were previously produced by
your system to this Committee in response to either our July 16, 2003 or
February 10, 2005 letter, you do not need to produce again any such documents,
but rather you may incorporate them in your response to this letter by reference
to specific Bates ranges from the earlier production. Finally, for the purpose
of your response to this letter, please limit your search for documents and
information, where appropriate, to the three largest hospitals (by net patient
revenue) in your system.
Please respond to these Requests in accordance with the definitions
attached to this letter and otherwise provided herein. Additionally, please also
respond to these Requests pursuant to the following definitions:
"Patient billing records" mean:
Any statements, reports, forms, invoices, or other such record, made for any
internal or external use whatever, relating to the accounting of the charges or
payments for health care services rendered to a specific patient. For the
purposes of this letter, "patient billing records" does not mean any general
hospital accounting or financial records containing only aggregate patient
billing information.
"Patient medical records" mean:
Records typically completed by medical service providers documenting medical
services including emergency room records, recovery room records, anesthesiology
records, nursing medication notes, operation room records, nursing notes,
physicians' orders, or discharge summaries.
"Out-of-network services" mean:
Health care services provided to a patient with health coverage through an
insurer with whom the treating health provider does not have any relevant
payment contract or agreement.
Finally, for the purposes of these Requests, please do not provide any
patient names or patient specific or individually identifiable health
information. Further, please do not produce any records which relate only to the
accounts of individual, specific patients.
1. Please provide the first 500 items that appear on the current charge
masters of your 3 largest hospitals. This list should be printed, copied, or
otherwise produced in whatever form it is typically kept. The items should
include any and all service or supply descriptions, associated codes or
references, and associated prices or charges.
a. Are these item descriptions and charges those that would appear on
patient billing records - for example, in an itemized statement?
2. Please state under what circumstances the description of an item in
your charge master would be changed. Please state the last 5 changes made to the
descriptions in each of the charge masters discussed above in response to
Request No. 1 and the reasons for such changes.
3. Describe each type of patient billing record created by your system and
state under what circumstances each such record is created. Also, please
indicate any differences between the patient billing records created for
patients based on the party responsible for payment (e.g., Medicare patients vs.
self-pay patients).
4. Provide a representative copy of each type of patient billing record
presently created by your system.
5. Are all patient billing records available upon request by the subject
patient?
a. If not, which patient billing records are not available and why are
they not available?
b. Are any patient billing records available to the patient only for a
fee?
6. Does your system generate for every patient a standard health insurance
claim form "UB-92" or all information necessary for a "UB-92" form? If
so, are all patients allowed to have, upon request, a "UB-92" form related
to their treatment and, if not, why?
7. Provide all written policies and procedures related to giving patients
access to the patient billing records related to their treatment including, but
not limited to, UB-92 forms.
8. Describe your policies and procedures regarding requests by a patient
or other payor for information about the terms, codes, or charges on their bill
and requests for an audit of their bill.
9. Provide all written policies and procedures related to requests by a
patient or other payor for information about the terms, codes, or charges on
their bill and requests for an audit of their bill.
10. Do you believe that the typical patient is able, without detailed
consultation with the hospital, to understand your patient billing records as
presented and determine whether the services and supplies listed on the records
were appropriate and related to their care?
11. Provide a list and description of each unique coding or reference
system used within your hospital system in its patient billing records with
respect to any revenue, service, supply, or charge such as any revenue codes,
service numbers, batch references, procedure codes, charge codes, reference
numbers, service codes, or charge master numbers. Please also indicate which
hospitals within your system uses each such coding or reference system.
12. Provide any studies, evaluations, or reports on the clarity,
readability, or understandability of patient billing records and any written
policies or procedures related to managing customer inquiries or complaints
about the clarity, readability, or understandability of patient billing records.
13. Are all patient medical records available upon request by the subject
patient?
a. If not, which patient medical records are not available and why are
they not available?
b. Are any patient medical records available to the patient only for a
fee?
14. Are you familiar with the practice of "unbundling" charge master
items and does such a practice take place in your system? If "unbundling"
takes place, please state:
a. When and why are items "unbundled" on your charge master?
b. Does the total charge for items when unbundled ever exceed the total
charge for the single aggregate item?
c. Please produce all records related to plans for the unbundling of any
items on any charge masters in your system.
15. During the course of this review, some hospital systems had suggested
that, although charge master prices may be high, few parties in reality paid the
full charge. As such, describe under what circumstances parties pay at or near
full charge master rates or near to charge master rates given only standard or
prompt pay discounts. Please identify such instances and parties, including any
related third-party payor.
16. For the period beginning January 1, 2000, and for each subsequent
year, please state the three largest single payors to your system excluding all
federal or state health plans, or group health insurers such as any maintenance
organizations or preferred provider organizations.
17. For the period beginning January 1, 2000, and for each subsequent
year, please state the following information for your system: the net revenue
collected per patient day for (a) all group health insurance; and (b) all other
insurance, including but not limited to, automobile insurers.
18. Do patients ever pay prices based on a charge master for
out-of-network services? If so, is this ever at or near the full charge master
price?
19. Have you ever sought payment for out-of-network services from a
patient individually (not including deductible or co-payment amounts), by any
means, for prices based on a charge master when part of the bill had already
been covered by a group health insurance payor? If so, under what circumstances
does this occur?
20. Provide all written policies and procedures related to billing and
collection of "out-of-network" patients.
21. For the period beginning January 1, 2000, and for each subsequent
year, please state the following information with respect to out-of-network
services for your system: (a) the gross billing per patient day; (b) the net
revenue collected per patient day; and (c) total number of patient days.
If you have any questions, please contact Anthony M. Cooke, Majority
Counsel for Oversight and Investigations, at (202) 226-2424.
Sincerely,
Joe Barton
Chairman
Ed Whitfield
Chairman
Subcommittee on Oversight and Investigations
cc: The Honorable John D. Dingell, Ranking Member
The Honorable Bart Stupak, Ranking Member
Subcommittee on Oversight and Investigations
####
|
