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Trend | Self-Payment Collection

Self-Pay Transparency in Colorado: What the Law Says

Trend | Self-Payment Collection

Self-Pay Transparency in Colorado: What the Law Says

Colorado’s Transparency in Direct Pay Health Care Prices Act requires health facilities to publish online the self-pay prices of their 50 most-used DRG codes and the 25 most-used CPT codes.

The Transparency in Direct Pay Healthcare Prices Act, effective Jan. 1, requires health facilities to post the 50 most-used diagnosis-related group (DRG) codes and the 25 most-used current procedural terminology (CPT) codes. Elements of the law:  

  • The information must be provided in a single document or made available on a facility’s website, which is updated at least annually.
  • It must include only codes for services of procedures that the facility used at least 11 times in the previous 12 months.
  • Service descriptions must be in plain English.
  • The posting must include a disclosure that the price for a specific service is an estimate and that actual charges will depend on the circumstances at the time the service is rendered.
  • This statement—or one that is substantially similar—must be posted: “If you are covered by health insurance, you are strongly encouraged to consult with your health insurer to determine accurate information about your financial responsibility for a particular healthcare service provided at this healthcare facility. If you are not covered by health insurance, you are strongly encouraged to contact (insert office name and telephone number) to discuss payment options prior to receiving a healthcare service from this healthcare facility since posted health care prices may not reflect the actual amount of your financial responsibility.”
  • Facilities may, but are not required to, disclose the basis for their prices and they may take into consideration all payer sources when determining a price.
  • Facilities may report the price during the previous 12 months in one of three ways:
    • The price charged most frequently for the healthcare service
    • The highest charge from the lowest half of all charges for the healthcare service
    • A range that includes the middle 50 percent of all charges for the healthcare service.
  • Facilities are not required to report prices to any agency for review, and no government agency has the authority to approve or disapprove prices.

What the Colorado Hospital Association Recommends

The Colorado Hospital Association’s Board of Trustees adopted a resolution in support of hospital transparency in July 2017. It recommends hospitals take the following actions:

  • For Colorado residents with incomes above 250 percent of the Federal Poverty Level, hospitals should not ask patients to pay more than the average negotiated rate across private health plans for emergency or other medically necessary care.
  • In addition to the requirements of the new state law, hospitals should:
    • Post an average or range of facility fee charges for emergency department (ED) visits, categories by acuity levels 1-5.
    • Post a list of average or range of charges for the most common outpatient diagnostic tests and procedures associated with ED visits.
  • Hospitals should prominently display on their websites the policies and procedures patients should use to file a billing complaint or grievance.
  • Hospitals should inform patients that they may receive multiple bills for services provided in a hospital facility and that physician, lab, and radiology services, among others, may come from different entities and are owed separately from the hospital bill.

Source: Colorado Hospital Association

See related article:  Colorado Systems Increase Price Transparency for Self-Pay Patients

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