With extra outpatient care being delivered in hospital outpatient departments (HOPDs) than in earlier years on account of vertical consolidation, shoppers more and more face excessive hospital facility payment costs on high of their supplier’s invoice for routine medical care. These facility charges are a profitable income stream for hospitals, however they place a big monetary burden on shoppers.
Growing consciousness in regards to the progress within the quantity and prevalence of those costs has pushed many states to deal with this concern of their state legislatures. A number of states pursued reforms that may restrict hospitals’ skill to cost outpatient facility charges and higher shield shoppers from such costs. States additionally sought to construct their inside capability to deal with these subjects by requiring larger transparency and commissioning research. Hospitals’ opposition to facility payment reforms has been fierce, nonetheless, and solely a handful of states have introduced their payments over the end line throughout the 2024 legislative session.
State Laws to Regulate Outpatient Facility Charges
States Throughout the End Line
Maine, Maryland, and Connecticut efficiently handed laws concerning facility charges this session. Notably, every of those states has enacted some facility payment reforms previously, as documented in CHIR’s 2023 report and concern temporary on state regulation of outpatient facility charges. Passage of the newest laws in these states emphasizes the incremental nature of reform on this space.
As CHIR reported final yr, Maryland at the moment requires hospitals to supply written and oral notices to shoppers when charging a facility payment for outpatient clinic companies, provides, or gear, excluding emergency division companies. This yr, Maryland legislators thought of payments that may develop these notification necessities to extra companies and suppliers. Legislators, going through pushback, finally handed a invoice that doesn’t change present necessities for hospitals, however duties the Maryland Well being Companies Price Assessment Fee to review outpatient facility payment billing and associated reforms with the purpose of convening a multi-stakeholder workgroup on increasing discover necessities. These efforts are anticipated to generate suggestions to the legislature for future motion later this yr and in 2025.
Each Connecticut and Maine have prohibitions on outpatient facility payment billing already on their books. Connecticut prohibits off-campus HOPDs (excluding freestanding emergency departments) from charging such charges for analysis and administration (E&M) and evaluation and administration (A&M) companies, and can lengthen this prohibition to on-campus amenities in July (topic to some exclusions). Connecticut additionally has a soon-to-expire prohibition on facility charges for telehealth companies that dates to the COVID-19 pandemic. This session, the Connecticut legislature prolonged its prohibition on facility charges for telehealth companies that dates to the COVID-19 pandemic and had been set to run out on the finish of June 2024.
Maine has restricted facility payment billing for care offered in workplace settings for almost 20 years. Following information stories on sufferers going through sudden facility payment costs, state legislators revisited the subject final yr, finally making a job drive to judge facility payment billing and make legislative suggestions. This regulation additionally required Maine’s all payer claims database to provide annual stories on facility payment costs. Based mostly on the duty drive’s report, Maine lawmakers handed laws requiring well being care entities to publish facility payment notices on their web site and on-site. These notices should advise sufferers whether or not the entity is a hospital-based facility, and in that case, determine the hospital or well being system that owns or operates the entity and whether or not or not it costs facility charges. The discover should additionally direct shoppers to a state company web site with extra details about the circumstances by which facility payment costs are permitted. Maine legislators additionally enacted a invoice requiring that well being care facility claims determine the bodily location the place a service was offered, together with hospital off-campus areas.
Notable Efforts
Further legislators throughout the nation launched a variety of measures to reform or make clear facility payment billing, however their payments didn’t go earlier than their state’s legislative classes ended.
Lawmakers in Washington sought to ban off-campus facility payment billing, along with increasing the state’s client notification necessities and introducing clear billing necessities on claims varieties. Different states launched proposals prohibiting suppliers from charging facility charges for a extra narrowly tailor-made set of procedures and care settings. Legislators in Connecticut sought to develop facility payment prohibitions to off-campus drug administration and injection and infusion companies, and require off-campus HOPDs to accumulate a novel nationwide supplier identifier and use this on all claims. Vermont legislators proposed to restrict sure outpatient facility payment billing, however didn’t specify which objects or companies needs to be affected.
Different states targeted solely on transparency necessities. Legislators in Florida sought to strengthen their present client notification necessities for facility charges, which might have continued to be embedded inside good religion estimates for non-emergency procedures.
In Indiana, a state that handed limitations on outpatient facility payment billing at off-campus HOPDs owned by giant non-profit well being programs in 2023, lawmakers launched a invoice that may require hospitals to report sure possession data to the Division of Well being. As a result of will increase in outpatient facility payment billing are largely pushed by hospital acquisitions of outpatient practices, possession data can present vital insights for state policymakers all for facility payment reforms. The proposal handed the Home, however finally died within the Senate.
Nonetheless Operating
Three states are nonetheless contemplating facility payment reform payments as their legislative classes stay open.Illinois lawmakers launched a invoice that attracts on Connecticut’s prohibitions on outpatient facility payment billing and notification necessities, whereas Arizona legislators launched a proposal that may prohibit sure outpatient facility charges and create new reporting necessities for hospital-owned or affiliated outpatient amenities. As well as, a number of facility reform payments stay pending in Massachusetts from 2023. These payments had been just lately referenced in a invoice that, if enacted, would order the Home Well being Care Financing Committee to review the problems the payments increase and make suggestions by the tip of the calendar yr.
Wanting Ahead
States proceed to contemplate further reforms for addressing hospitals’ apply of charging facility charges for outpatient companies. When classes convene in 2025, we anticipate there will likely be extra exercise and continued curiosity on this concern. CHIR’s cheat sheet is a useful useful resource for policymakers when contemplating completely different facility payment reform methods. Policymakers and advocates contemplating facility payment reforms are inspired to contact CHIR specialists for technical help at [email protected].