With extra outpatient care being delivered in hospital outpatient departments (HOPDs) than in earlier years as a consequence of vertical consolidation, shoppers more and more face excessive hospital facility payment prices on prime 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 concerning the progress within the quantity and prevalence of those prices has pushed many states to handle this challenge of their state legislatures. A number of states pursued reforms that will restrict hospitals’ capacity to cost outpatient facility charges and higher defend shoppers from such prices. States additionally sought to construct their inside capability to deal with these subjects by requiring higher 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 in the course of the 2024 legislative session.
State Laws to Regulate Outpatient Facility Charges
States Throughout the End Line
Maine, Maryland, and Connecticut efficiently handed laws relating to facility charges this session. Notably, every of those states has enacted some facility payment reforms prior to now, as documented in CHIR’s 2023 report and challenge transient 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 12 months, Maryland presently 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 12 months, Maryland legislators thought of payments that will increase these notification necessities to extra companies and suppliers. Legislators, dealing with pushback, finally handed a invoice that doesn’t change current necessities for hospitals, however duties the Maryland Well being Companies Value Evaluation Fee to check outpatient facility payment billing and associated reforms with the objective 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 12 months 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 services 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 supplied in workplace settings for almost twenty years. Following information studies on sufferers dealing with sudden facility payment prices, state legislators revisited the subject final 12 months, finally making a activity drive to guage facility payment billing and make legislative suggestions. This regulation additionally required Maine’s all payer claims database to provide annual studies on facility payment prices. Primarily based 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 if that’s the case, establish the hospital or well being system that owns or operates the entity and whether or not or not it prices facility charges. The discover should additionally direct shoppers to a state company web site with extra details about the circumstances wherein facility payment prices are permitted. Maine legislators additionally enacted a invoice requiring that well being care facility claims establish the bodily location the place a service was supplied, together with hospital off-campus places.
Notable Efforts
Further legislators throughout the nation launched a spread of measures to reform or make clear facility payment billing, however their payments didn’t move earlier than their state’s legislative periods ended.
Lawmakers in Washington sought to ban off-campus facility payment billing, along with increasing the state’s shopper notification necessities and introducing clear billing necessities on claims kinds. 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 increase facility payment prohibitions to off-campus drug administration and injection and infusion companies, and require off-campus HOPDs to amass 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 must be affected.
Different states targeted solely on transparency necessities. Legislators in Florida sought to strengthen their current shopper 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 methods in 2023, lawmakers launched a invoice that will 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 fascinated by facility payment reforms. The proposal handed the Home, however finally died within the Senate.
Nonetheless Working
Three states are nonetheless contemplating facility payment reform payments as their legislative periods 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 will prohibit sure outpatient facility charges and create new reporting necessities for hospital-owned or affiliated outpatient services. As well as, a number of facility reform payments stay pending in Massachusetts from 2023. These payments have been not too long ago referenced in a invoice that, if enacted, would order the Home Well being Care Financing Committee to check the problems the payments elevate and make suggestions by the top of the calendar 12 months.
Wanting Ahead
States proceed to contemplate further reforms for addressing hospitals’ observe of charging facility charges for outpatient companies. When periods convene in 2025, we anticipate there might be extra exercise and continued curiosity on this challenge. CHIR’s cheat sheet is a beneficial useful resource for policymakers when contemplating completely different facility payment reform methods. Policymakers and advocates contemplating facility payment reforms are inspired to contact CHIR consultants for technical help at FacilityFeeTA@georgetown.edu.
