Intended to better protect and serve consumers, there are three distinct regulations defining the price transparency landscape. Seen below, they aim to create a more transparent healthcare experience:
- Hospital Price Transparency
- Transparency In Coverage Final Rule
- No Surprises Act
Hospital Price Transparency helps Americans understand the cost of a hospital item or service before receiving it. Starting January 1, 2021, each hospital operating in the United States is required to provide clear, accessible pricing information online about the items and services they provide.
The Transparency in Coverage Final Rule, issued by the Centers for Medicare and Medicaid Services (CMS), requires health insurers to disclose pricing for covered services and items. Insurers must include the rates they have negotiated with participating providers for all covered services and items, as well as the allowed and billed amounts for out-of-network providers.
The No Surprises Act (NoSA) tackles a different price transparency problem: patients often receive large and confusing bills after emergent or out-of-network care. As of 1/1/2022, NoSA limits the amount patients can be charged to the in-network rate.
Price transparency in healthcare refers to the availability and accessibility of information about the costs of healthcare services to patients, providers, and payers. This information can include prices for medical procedures, services, and prescription drugs, as well as information about the prices that insurance companies pay to providers.
A good faith estimate (GFE) in healthcare is a document that provides an estimate of the costs a patient will likely be responsible for paying out-of-pocket for a specific medical procedure or service. GFEs are intended to provide patients with more transparency and predictability about their healthcare costs and help them plan for and manage the financial aspects of their care.
Understanding the cost of a visit is important for patients because it can help them make more informed decisions about their healthcare. When patients have a clear understanding of the costs associated with a visit, they can make more informed decisions about their care, such as choosing a less expensive treatment option or seeking care from a provider who charges lower rates. Additionally, having cost information can help patients plan for and manage the financial aspects of their care.
Furthermore, when patients are aware of the cost of a visit, they can also negotiate with their healthcare provider for a lower cost, or look for alternative solutions. This can also help patients avoid unexpected medical bills which can be a huge financial burden.
Additionally, transparency in healthcare pricing can also help to promote competition among healthcare providers, potentially leading to lower costs for patients. The Transparency Coverage Final Rule issued by the Centers for Medicare and Medicaid Services (CMS) aims to increase transparency in healthcare pricing by requiring certain health insurance plans to disclose information about their prices and payments to healthcare providers.
Adonis supports developers who want to enable providers with the capability to share personalized and accurate clinical care cost estimates for their patient population. Our APIs pull information from various data sources, including negotiated contracts, regional averages, eligibility data, plan benefits, deductibles, and more.
Simply put, we do the hard work so you don’t have to. The Price Transparency API not only allows providers to pull accurate care cost data, it also enables them to create automated workflows for quoting clinical services, creating patient-first functionality, or patient self-serve applications.
For providers with an appetite to take the patient experience to another level, Adonis has built a set of price transparency applications that can be used out of the box. Adonis supports providers in being compliant with the new legislation by offering automated workflows to be embedded within a patient’s onboarding or scheduling flow. With Adonis, providers can feel at ease knowing that they’re not at risk of being fined while patients can begin to trust their providers and retain as patients longer.
For existing Adonis users, you can get in touch with your Adonis product support manager to learn more about mitigating underpayments.