OR Manager August 2023 - 21

Finances
Takeaways
* Healthcare consumers are not aware that they can ask how much something costs.
* There is disconnect between the law and common knowledge, and patients generally are confused about what they receive
as good faith estimates.
* In addition to incorrect CPT codes and OON allowable charges, the changing cost of an implant or supply can cause an
estimate to differ significantly from a bill.
Price transparency, Vo
Continued from page 1
ties and co-providers, price transparency
may also soon apply to ambulatory surgery
centers (ASCs) as co-facilities, and
anesthesiologists as co-providers. Hospitals
are already required to post their
standard charges under the Hospital
Price Transparency rule (sidebar), which
went into effect on Januaty 1, 2021.
As a patient advocate,
Gary Richberg,
DNP, MBA, MSN, RN,
CASC, a healthcare executive,
says patients
should understand what
the costs of their medical
care will be. With a
lack of understanding,
patients can become
frustrated with their providers
and health insurGary
Richberg,
DNP,
MBA,
MSN, RN,
CASC
ance, and they may avoid healthcare
services altogether. Transparency is essential
for creating trust and reducing
confusion between healthcare providers
and patients.
Barriers and challenges
Biraj Patel, MD, an anesthesiologist
practicing
in New York City and
founder of PreferredMD,
a physician referral service,
believes the cost
of healthcare is unsustainable,
but he sees
GFEs creating more inefwork
providers or are uninsured receive
a GFE, which is automatically generated,
they may ignore it, or they may become
confused, he says. In addition, GFEs
may not reflect a patient's condition.
A GFE is accurate only if it is based
on a known diagnosis and clear treatment
plan. Richberg sees this as a challenge
because diagnoses and treatment
plans can change and increase the cost
of care. Providers do not intentionally
drive up the bills, he says; it is just part
of the risk of relying on GFEs.
Dr Patel explains that when a patient
is having a surgical procedure, each
component of the procedure is assigned
a separate Current Procedural Terminology
(CPT) code. The surgeon may
anticipate three codes, but the procedure
may end up having seven codes
because the patient's condition required
additional
interventions. Each time a
CPT code is added, another value is
added to the bill. Generating an accurate
GFE is very difficult because in
many cases, it is hard to know which
CPT codes are going to be applied to
that procedure.
Out-of-network reimbursement models
also vary from insurance to insurance,
plan to plan, and patient to patient.
Two patients can have the same
procedure with the same surgeon andwith
the same implants, but end up having
totally different financial responsibilities,
Dr Patel says.
Biraj Patel,
MD
ficiencies than providing benefits in the
current environment.
Dr Patel says patients lack knowledge
about GFEs and, therefore, feel
anxious rather than protected by them.
When patients who are using out-of-netwww.ormanager.com
Another
reason a GFE can differ
significantly from a bill is that implant
costs vary, and the one used in the
procedure may differ from the one used
for the GFE, sometimes in the thousands.
Dr Patel notes that facilities do
their best to provide an approximate
value. But Richberg acknowledges that
patients may get frustrated and even
angry with their healthcare providers,
and they may feel a loss of trust, if their
procedure turns out to be more complicated
or more expensive.
CMS recognizes that variances occur
between GFEs and bills and allows patients
to file disputes if their bills are at
least $400 higher than their GFEs. However,
this amount is being challenged by
various professional groups,
the American Hospital Association.
including
Provider-payer coordination
To provide an accurate GFE, healthcare
providers, facilities, and insurance plans
need to coordinate to understand a patient's
diagnosis, CPT and other billing
codes, insurance coverage, and allowable
out-of-network charges. This extensive
level of coordination is often not
feasible, especially under the NSA.
Richberg notes the healthcare environment
has become more confusing
over the years. " The challenge is how
we, as consumers, begin to understand
what we are getting from our healthcare
insurance, what we are getting from our
providers, and what the relationships
look like among patients, providers, and
healthcare payers. Unfortunately, patients
don't always know what these
relationships look like, " he says.
As the rules change, healthcare providers,
patients, and their families are
still learning. " We have an obligation to
help the patient understand as much
as we can. As a provider, you have to
be an advocate for that patient, " says
Richberg. " But overall, it's the patient's
responsibility. We can't be everything to
patients. We can't be health providers
and financial counselors, " he adds.
Dr Patel's experience is similar. " We
spend a lot of time explaining what this
means to patients, " he says. " Front
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