See List of charges (fees) for specific procedures that may be performed in a medical office. However, some consumers report being told that they had no right to dispute inaccurate bills placed on a medical payment product, even if they discovered after enrolling in the payment product that they were billed in error or that their bill should have been covered by insuranceor even if they never received the service at all. Journal of Health Economics, 5, 129151. 45. Peterson-KFF, Shameek Rakshit, Emma Wager, Paul Hughes-Cromwick, Cynthia Cox, and Krutika Amin, How does medical inflation compare to inflation in the rest of the economy? (March 2023), available at https://marketplace.cms.gov/outreach-and-education/what-you-should-know-provider-networks.pdf. If you require this document in an alternative electronic format, please contact Do companies limit where or how patients use medical credit cards? Have you ever felt pressured to pay for care using a medical payment product or general purpose credit card when you believed that was not in your best interest? available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf. Carine Milcent. Many medical payment products charge interest and fees, including deferred interest, which may significantly increase the amount patients owe for their care. The three national credit reporting companies forbid credit reporting of medical debt collections items with original balances under $500 or which are less than one year old, but these restrictions do not apply to debt collections items reported with classification codes indicating that they are credit card or installment loan collections. These must be distinguished from stays coded by a J. 4 II. What are Here, we'll talk about upcoding and downcoding, and cover the risks of both - and how to deal with these circumstances. R-3826-HCFA. 44. reduction for start/stop infusion times. Pohlman, J. T., & Leitner, D. W. (2003). Google Scholar. available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf. an additional CPR code tha5 indicates unusual circumstances related to the procedure. available at https://www.irs.gov/charities-non-profits/limitation-on-charges-section-501r5. Medical credit card companies include CareCredit, a subsidiary of Synchrony Financial; Wells Fargo; and Comenity, a subsidiary of Bread Financial. (CLASS ACTION SUITS ON THE RISE), Doctors Suing Insurers Over Denied Claims. 5. are not part of the published document itself. Register documents. Its impact is given as follows. In this Request for Information (RFI), CFPB, HHS, and Treasury seek comment on the prevalence, nature, and impact of medical payment products on consumers and on the health care system. Economie Publique, 13, 331. 34. Attachment Requirements. How do medical payment product companies' debt collection practices differ from those of health care providers, and are any issuer or provider debt collection practices posing risks to consumers? Internal Revenue Service, Billing and CollectionsSection 501(r)(6), (July 22, 2022), 25. Updated on February 24, 2020 Fact checked by Elaine Hinzey, RD Upcoding is fraudulent medical billing in which a bill sent for a health service is more expensive than it should have been based on the service that was performed. Are different types of health coverage treated differently? [47] CMS, Hospital Price Transparency Enforcement Updates, [10] 28. First, changes to private health care coverage may incentivize providers to promote medical payment products. Health care payment systems: Cost and quality incentives? 36. I multiplied this effect by average fee for patient coded as DRG level 2. are considered in underwriting? 5. 8. CMS20230106, P.O. Secondly, the agencies seek to understand the impacts of these products on patients' financial health, including through high interest rates and fees, credit scoring or other scoring products, credit reporting practices, and debt collection practices. 2. 6. Kenneth P. Brevoort & Michelle Kambara, Data point: Medical debt and credit scores (May 2014), The medical installment loan market includes a large number of companies, among which some of the most prominent are AccessOne, Prosper, PayZen, Walnut, and Scratchpay. The White House, FACT SHEET: New Data Show 8.2 Million Fewer Americans Struggling with Medical Debt Under the Biden-Harris Administration (Feb. 2023), This information is not part of the official Federal Register document. Health Policy, 76, 2637. Both involve how you code services rendered when you file a claim for payment, and both can have an impact on revenue. Comment IntakeRequest for Information Regarding Medical Payment Products, Consumer Financial Protection Bureau, 1700 G Street NW, Washington, DC 20552. On further review a growing number of third-party medical bill review companies are being named in patients' and providers' lawsuits, Aetna, CIGNA cases put different spin on claims fraud, MORENO APPROVES AETNA AGREEMENT IN PHYSICIAN CLASS ACTION, Doctors Suing Insurers Over Denied Claims. 46. Washington State Office of the Attorney General, AG Ferguson files lawsuit against Swedish, other Providence-affiliated hospitals, for failing to make charity care accessible to thousands of Washingtonians, or geographic regions that experience disproportionately higher utilization of medical payment products? e.g., see The number of medical installment loan providers is much greater than the number of medical credit card lenders, and these products vary in many ways. The New England Journal of Medicine, 318(6), 352355. See Office of Inspector General (OIG) Advisory Opinion 0212 at 11 ([H]ealth care providers are in a position of trust and may exert undue influence when recommending health care related items or services, particularly to their own patients.). The OFR/GPO partnership is committed to presenting accurate and reliable Missing Mod sed flow sheet. The third is to increase revenue per stay. Ge Bai, & Gerard F. Anderson, US Hospitals Are Still Using Chargemaster Markups to Maximize Revenues (Sept. 2016), Health Affairs, available at https://www.cms.gov/newsroom/fact-sheets/hospital-price-transparency-enforcement-updates. The Association between for-profit Hospital Ownership and Increased Medicare Spending. [41] or the national credit reporting companies' voluntary decision not to report medical collections that are paid, under $500, or less than a year old. The agencies also seek to understand the extent to which health care providers, including tax-exempt hospitals, screen patients for public or private insurance eligibility, financial assistance eligibility, or other benefits before offering them medical credit cards or loans. 210. Correspondence to 2. It was viewed 158 times while on Public Inspection. Upcoding is a fraud that involves billing payers for more expensive procedures and treatments than those provided. (2004). Pricing the priceless: A health care conundrum. The American Economic Review, 95(5), 15251547. i. ClearBalance HealthCare, Experience to Solve Patient Pay, CFPB, Medical debt burden in the United States, at 3235, Given these overlapping equities, the agencies are committed to working together to understand and address the harms medical payment products may cause, as part of their work more generally on health care costs, medical billing, and medical collections. i. informational resource until the Administrative Committee of the Federal the official SGML-based PDF version on govinfo.gov, those relying on it for The RAND Corporation. The New England Journal of Medicine, 341(6), 420426. These tools are designed to help you understand the official document As a result, patients may feel pressured or coerced into signing up for medical payment products that cause downstream financial or health problems, including through debt collection or credit reporting of medical bills that might have inaccurate information. The result would be a fee per group based on manipulated factors that would lead to an inefficient budget allocation between hospitals. available at https://oag.ca.gov/news/press-releases/attorney-general-bonta-issues-consumer-alert-following-reports-hospitals-failing; Register, and does not replace the official print version or the official The RAND Corporation. 39. Medicare upcoding and hospital ownership. Because paper mail in the Washington, DC area and at the Bureau is subject to delay, commenters are encouraged to submit comments electronically. Extraordinary collection actions include credit reporting an unpaid medical bill, deferring or denying care to a patient due to their unpaid medical bills, taking legal or judicial action to recoup an alleged medical debt, or selling an alleged medical debt. [15], Medical payment products are administered by financial services companies, who manage the billing and collections process for these products and earn revenue through interest and fees. https://www.bokfinancial.com/-/media/Files/PDF/Commercial/Healthcare/CBHC_Overview.ashx. How might HHS improve patient understanding of options for covering the cost of medical treatments? Federal Register provide legal notice to the public and judicial notice This information should not be considered complete, up to date, and is not intended to be used in place of a visit, consultation, or advice of a legal, medical, or any other professional. Audrey Kearney Patients might also avoid or delay care if they are unaware of the availability of financial assistance and other affordable financing options or are concerned about their ability to pay their health care bills. Scandinavian Journal of Economics, 113(2), 444469. HHS is interested in whether incentives offered to health care providers by financial companies may implicate the Federal anti-kickback statute. available at https://www.aeaweb.org/articles?id=10.1257/aeri.20210515; available at https://choicepays.com/choicepays/. 202314726 Filed 71123; 8:45 am], BILLING CODE 4810AMP; 412001P; 4810AKP. The aim of both strategies is to reclassify patients into higher-severity DRGs with a higher associated payment rate, a phenomenon known as upcoding. Why or why not? the material on FederalRegister.gov is accurately displayed, consistent with Additionally, some financial services companies offer health care scoring products designed for health care providers, such as financial clearance scores and propensity-to-pay scores, which can be used to restrict access to care and promote payment products rather than financial assistance for those eligible. 26. Learn more about Institutional subscriptions. In what follows, this level is called low or non-severe. PubMedGoogle Scholar. rendition of the daily Federal Register on FederalRegister.gov does not Hospitals are paid a fixed price for each patient admitted in hospital. Thomas West, Deputy Assistant Secretary, U.S. Department of the Treasury at [36] Wall Street Journal Or, do providers have arrangements with financial companies to indemnify the company in whole or in part if the patient defaults, such as an arrangement that when patients default on their debt to the financial company, the debt reverts to the provider? What steps are taken by health care providers to ensure these charges are adequately disclosed in accordance with hospital price transparency requirements? Hospital market structure and the behavior of not- for-profit hospitals. medical procedure, credit score, etc.) This repetition of headings to form internal navigation links Have you ever tried to dispute a medical bill you paid using a medical credit card or loan? E/M downcoding policies 4 III. How do tax-exempt hospitals' promotion of medical payment products compare to their operationalization of the requirement that their financial assistance policies be widely publicized? A DataBook: Healthcare spending and the medicare program (Washington: Med- PAC, June 2005), 102. Journal of Health Economics, 23(2), 369389. Do health care providers or financial institutions market or recommend medical credit cards or loans to Federal health care program beneficiaries ( Health Economics, 26(5), 600618. Health Economics, Center for National Scientific Research, CNRS Paris School of Economics PSE, 48 Bd Jourdan, 75014, Paris, France, You can also search for this author in Have you ever used or been pressured to use a medical credit card or loan to pay a bill that you believe should have been covered by your health care provider's financial assistance policy? Anything already paid or under $500 should no longer be on your credit report, 2022), HHS, HHS Kicks Off New Year with New Protections from Surprise Medical Bills, The type of insurance. Additionally, section 501(r) of the Internal Revenue Code (IRC) prohibits tax-exempt hospital organizations from engaging in extraordinary collection actions, including reporting the patient's debt to credit reporting companies or sending the patient's debt to a third-party debt collector, before the organization has made reasonable efforts to determine whether the individual is eligible for assistance under the hospital's financial assistance policy. b. 43. In general, the agencies welcome any information that allows us to better understand the impact of medical payment products on patients' physical, mental, and financial health. The risk of up-coding in casemix systems: A comparative study. age, type of Shleifer, A. available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf. You may submit responsive information and other comments, identified by Docket No. available at https://www.consumerfinance.gov/about-us/blog/medical-debt-anything-already-paid-or-under-500-should-no-longer-be-on-your-credit-report/. In other cases, patients whose predicted income and household size would qualify them for financial assistance, but who have a higher predicted propensity to pay, are channeled to medical payment products instead of being offered financial assistance. Internal Revenue Service, Limitation on ChargesSection 501(r)(5), Impacting Patient Care through Neglectful Coding Errors Every practice strives to provide quality patient care as a cornerstone of their existence. available at https://www.consumerfinance.gov/data-research/research-reports/medical-debt-burden-in-the-united-states/; Experian, Patient Financial Clearance, HHS also seeks specific comments from all Indian Health Care Providers, including Indian Tribal Governments, Tribal Organizations, and Urban Indian Organizations about medical credit card and loans and the role they play in the Indian health care provider billing environment. [32] 5. this will NOT be posted on regulations.gov. This PDF is Downcoding is the total opposite of upcoding in medical billing. as well as CFPB guidance to prevent unlawful medical debt collection and reporting. Kimberly, J.R., de Pouvourville, G., & DAunno, T. The agencies also seek to understand the effects these products may have on patients and on the health care system. L & Soc. 37. the current document as it appeared on Public Inspection on TransUnion, TransUnion Healthcare and VisitPay: A Patient Financial Engagement Solution, Health Affairs, 25(1), 7080. Cambridge: Cambridge University Press. 10. The authors declare that they have no conflict of interest. Are there different or other actions that agencies should consider for underserved communities, including Tribal communities and geographically isolated communities? If so, please describe your experience. B., Zuurbier, J. J., & Schaepkens, F. J. DREES (Direction de la Recherche, Etudes, Evaluation et Statistiques). Secondly, health care providers may be incentivized to promote medical credit cards and loans because these products result in faster payment, lower administrative costs, and more revenue overall for the health care provider compared to alternatives like financial assistance or provider-administered payment plans. 26. Using a unique French longitudinal database with 145 million stays, I unambiguously demonstrate that the implementation of a finer classification led to an upcoding-learning effect. Have you ever had an overdue bill on a medical credit card or loan sent to collections? Recognizing when claims are being downcoded 5 IV. Insurance payments will tend to be lower than average for the services. See, e.g., What policy actions should Treasury consider taking to address problematic practices related to medical credit cards or loans, including debt collection and credit reporting practices, to conform with the existing tax laws and regulations pertaining to tax-exempt hospitals? Follow the Submit a comment instructions. [26] CEPR Discussion Paper, N.6689. How can the CFPB use its authorities to ensure people with medical bills in collections, including medical payment product debt, are screened for eligibility for financial assistance and other benefits? 7. When a patient instead pays for medical services out-of-pocket or via credit card or installment loan, the health care provider avoids many of these costs and generally receives payment immediately or within days. This is a preview of subscription content, access via The letter Z indicates an exploratory stay, with no coding of severity. KFF, Healthcare Debt in the US: The Broad Consequences of Medical and Dental Bills, HHS is also responsible for regulation and oversight of Medicare, Medicaid and the Children's Health Insurance Program, and the Affordable Care Act Marketplaces, and shares responsibility for enforcement of Federal health care fraud and abuse laws, including the Federal anti-kickback statute. [20] This can happen through: (i) reductions in lengths of stay; (ii) reductions in the intensity of services provided; and (iii) patient selection. Where may additional statutory authority be needed? 7. For example, CareCredit grew from 4.4 million cardholders and 177,000 participating providers in 2013 to 11.7 million cardholders and over 250,000 participating health care providers in 2023. c. Patient Experience and Downstream Consequences, d. Risk of Exacerbating Billing and Financial Assistance Issues, e. Potential Distortion of Health Care Provider Incentives Americans' Challenges with Health Care Costs, KFF (July 14, 2021), Out-of-network health care providers might also offer medical payment products to patients instead of referring those patients to an in-network provider. KFF, Average Annual Deductible per Enrolled Employee in Employer-Based Health Insurance for Single and Family Coverage, http://www.regulations.gov. e.g., headings within the legal text of Federal Register documents. 1320a7b(b), the Federal anti-kickback statute, provides for criminal penalties for whoever knowingly and willfully offers, pays, solicits, or receives anything of value to induce or reward the referral, recommendation, or arranging for the referral or recommendation of business reimbursable under any of the Federal health care programs, including Medicare and Medicaid. documents to your comment. [31] Le panorama des tablissements de sant, Editions 2012. The agencies seek comment on how to ensure that patients retain their rights to challenge inaccurate bills regardless of payment method. Consumers report that errors in medical bills are common; among those with medical debt, more than four in ten say they received an inaccurate bill, and nearly seven in ten say they were asked to pay a bill that should have been covered by insurance.