The Washington State Hospital Association (WSHA) has often heard from state legislators who want patients to have access to better information about health care costs. WSHA supports transparency, but has been concerned that responding to requests for information about charges may not help in educating patients. We have told legislators one of the main issues with increased transparency about charges is they are not helpful to patients who want to know how much they will need to pay after their health insurance pays for care. Charges also are not relevant for charity care patients who will pay a discounted amount.
Yet, there is a strong push by legislators to provide additional information to patients. During the 2009 legislative session, a bipartisan group of legislators supported HB 1869 requiring hospitals and other health care providers to help patients understand more about charges for care. The bill had strong support and was unstoppable. WSHA was successful in amending the bill to make the responsibilities for hospitals realistic. Implementation of the new law, however, still requires work on the part of hospitals, as explained in more detail below.
New Legal Requirements
The law requires providers licensed under Title 18 Revised Code of Washington (RCW) (which includes physicians and other health care practitioners) and Title 70 (which includes hospitals) to provide estimated charges for services upon request of the patient.
To meet this requirement, by July 25, 2009, hospitals and other health care providers must post signs informing patients of their right to request information about estimated charges. Hospitals must post a sign in patient registration areas stating, “Information about the estimated charges of your hospital services is available upon request. Please do not hesitate to ask for information.” WSHA has developed a model sign which hospitals can order from the WSHA bookstore for free here.
The requirement to post a sign was preferable to the other legislative options under discussion, which included requiring each patient to sign a form stating the patient had been informed of the patient’s right to ask for charges. Posting a sign seemed to be a much simpler solution.
It is unclear how many patients will make a request for additional information. The number of requests may be small. We would appreciate hearing back from hospitals about their experience after the signs have been in place for a reasonable period of time.
The new law also requires providers and facilities to provide information regarding “other types of fees or charges a patient may receive in conjunction with their visit to the provider or facility.” Hospitals are already meeting this requirement by following an existing law (see RCW 70.41.400). The existing law requires hospitals to furnish each inpatient a written statement with a list of physicians and other professionals who commonly provide care for patients at the hospital and from whom the patient may receive a bill, along with their contact phone numbers. The new law recognizes hospitals do not need to provide any additional information for outpatients.
The new law also states providers and facilities may, after following their own legal requirements, refer the patient to the patient’s insurer for further information.
Estimating the Cost of Charges
Many hospital leaders are baffled by the requirements of this law. How is it possible to estimate the charges associated with hospital care? When a patient is experiencing ongoing inpatient care, the charges will change depending on the course a patient’s treatment takes. What happens when the charges associated with the care significantly differ from the estimate?
While WSHA does not have all the answers, we can offer some general guidance:
- Some hospitals have eased compliance with the types of requirements contained in this bill by estimating, in advance, a range of charges associated with the procedures the hospital most frequently performs. The range of charges is then available to patients who request information. The range of charges can also be made available on the hospital’s web site.
- When a patient asks for an estimate of charges, the hospital must comply. It is important to give the patient information as quickly as possible. If the patient’s circumstances make estimation of charges difficult, the hospital does not have to provide the information instantaneously. If the hospital requires time to develop the estimate, that patient should be told about how long preparing the estimate will take.
- In the case of emergency care and some hospitalizations, a hospital will not yet know what the “specific service, visit, or stay” is for the patient. The patient should be told it is not yet possible to provide an estimate.
- Anytime a patient requests an estimate, hospitals should emphasize it is only an estimate and health care needs can be unpredictable. Any change in the plan of care can change the amount of hospital charges significantly.
- A hospital should consider whether it will provide a written statement containing a disclaimer to patients who request an estimate. Hospitals might consider using language such as, “The hospital or clinic can provide estimates of charges for services. The estimates are not exact because we cannot know in advance the type and amount of care you and your provider will decide is needed. Your charges will depend on the actual services you receive.”
- Hospitals should train registration and other hospital staff to respond to requests appropriately and with concern for the patient. This includes informing patients about the availability of financial assistance. Special care must be taken with patient requests made in the emergency department. (See below.)
Requests in Emergency Departments
Federal law as contained in the Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide emergency treatment regardless of a patient’s ability to pay. EMTALA also prohibits delay of a medical screening exam and emergency treatment for the purpose of determining a patient’s financial obligations.
The requirement of hospitals to post signs in patient registration areas about a patient’s ability to request estimated charges information could prompt inquiries from patients about what their financial obligations related to the emergency care may be. In order to comply with EMTALA, WSHA believes any discussion with a patient about the charges for emergency care should be discouraged prior to the medical screening exam and emergency treatment. This recommendation is based on an advisory bulletin issued in 1999 by the Centers for Medicare and Medicaid Services that stated, “We also recommend that hospital staff encourage a patient who believes that he or she may have an emergency medical condition to defer any further discussions of financial responsibility until after the provision of an appropriate medical screening examination and the provision of stabilizing treatment if the patient’s condition warrants it.” 64 Fed. Reg. 61,355 (1999).
The following factors may help a hospital manage the intersection of state law and EMTALA in this area:
- If a patient requests information about emergency care charges, the patient should be informed the hospital will provide an estimate, but cannot do so until after the patient has been screened and received stabilizing treatment. Hospital staff should conduct this conversation in a way that emphasizes meeting the patient’s health care needs first.
- If the patient indicates he or she may leave because the information cannot be provided prior to screening and stabilization, hospital staff should convey the risks of going without health care.
- If a patient insists on leaving, the hospital should follow its policies and procedures for a patient’s refusal to consent to treatment, including documentation requirements.