SB2045
October 7, 2013
Medical cost transparency is a hot topic among business, academic and political leaders worldwide -- and a new Arizona law reflecting this trend goes into effect December 31. House Bill 2045 requires health care providers make available on request or online the direct pay price for their 25 most commonly provided services and update that price list at least annually. Failure to do so is considered unprofessional conduct, subject to discipline by the licensing board. The legislation applies to osteopathic physicians as well as to podiatrists, chiropractors, medical doctors, optometrists, physical therapists and occupational therapists.
Are there any exemptions?
Yes. Health care providers who are owners or employees of a legal entity with fewer than three licensed health care providers are exempt. Emergency services are exempt. Health care services provided by the Veterans Administration, military, Indian Health Service, tribal clinics, and the Arizona State Hospital are exempt.
What does "direct pay price" mean?
The price charged by a health care provider for a lawful health care service, regardless of the health insurance status of the person. This price must be for the standard treatment provided for that service, but may include the cost for complications or exceptional treatment.
How do I make this available?
Online or on request. The 25 services can be identified by CPT code or plain language.
How do I calculate my 25 most commonly provided treatments?
Probably by billing codes. You may use any 12 month period within the last 18 months to calculate your most common treatments.
Will I get any guidance from my licensing board?
The affected licensing boards have many questions as well about how the new law should work. As of now, there is no effort to interpret the law by the Arizona Attorney General's office or any of the licensing boards.
Anything else?
We understand this new mandate is fraught with legal, professional, contractual, ethical and antitrust difficulties.
Click here to download the pages that cover physicians. Print it out. You will want to at least discuss this with your office manager and, perhaps, others in order to make a good effort to comply with the law.
What if someone who is insured with a plan I accept wants the direct price?
Then you need to provide a consent form substantially similar to the one below to your patient or your patient's employer.
Important Notice about Direct Payment for Your Health Care Services
The Arizona Constitution permits you to pay a health care provider directly for health care services. Before you make any agreement to do so, please read the following important information:
If you are an enrollee of a health care system (more commonly referred to as a health insurance plan) and your health care provider is contracted with the insurance plan, the following apply:
1) You may not be required to pay the health care provider directly for the services covered by your plan, except for cost share amounts that you are obligated to pay under your plan, such as copayments, coinsurance and deductible amounts.
2) Your provider's agreement with the health insurance plan may prevent the heath care provider from billing you for the difference between the provider's billed charges and the amount allowed by your health insurance plan for covered services.
3) If you pay directly for a health care service, your health care provider will not be responsible for submitting claim documentation to your health insurance plan for that claim. Before paying your claim, your health insurance plan may require you to provide information and submit documentation necessary to determine whether the services are covered under your plan.
4) If you do not pay directly for a health care service, your health care provider may be responsible for submitting claim documentation to your health insurance plan for the health care service.
Your signature below acknowledges that you received this notice before paying directly for a health care service.