LRB 0920

 

DATE:		June 30, 2009
TO:		All Legislators
FROM:		Representative Leah Vukmir and Senator Ted Kanavas
RE:		Co-Sponsorship of LRB-0920/2 – The Patient’s Right To Know Act
The Patient’s Right to Know Act Health Care Transparency Wisconsin has been a pioneer in promoting health care price transparency, including the innovative web-based PricePoint system. Insurers are also providing online tools for their members to evaluate information about health care price and quality. These efforts have been effective at increasing the amount of information available to consumers, but more needs to be done. There is general, bi-partisan consensus that tools like these are help put patients in charge of their health care while encouraging them to become more conscious of health care costs. This bill compliments the online efforts currently in place. It also takes transparency to a new level by providing price information that is specific to an individual’s health status. No other transparency tool provides this type of information. This legislation provides the information patients are demanding from the providers of care – a good faith estimate. This legislation passed in the Assembly last session on a bipartisan vote. Provider Cost Estimates General provisions A patient may request a cost estimate from their provider for scheduled care that is anticipated to cost more than $500. If a patient wishes to consider options to reduce their cost-sharing or total cost of the procedure, the insurer may provide the patient with cost saving options or incentives to consider various providers.  The legislation is based on the simple premise that a patient has a right to know the cost of non-emergency procedures in the form of a good-faith estimate.  The estimate must include all services and practitioners that will be providing care related to the course of treatment. The patient is not forced to obtain this information on their own.  For diagnostic procedures and tests exceeding $500: A patient may request an estimate of the cost and appropriate codes to obtain coverage information from their insurer. For surgical and hospital care: A patient who has been referred for a schedulable surgical procedure or hospitalization, may request a provider cost estimate. The estimate: Represents the provider’s good-faith effort to provide accurate information to the patient or patient’s agent  Must include the anticipated costs of practitioners, facilities charges, anticipated length of stay (if any) and the per-day cost, an estimate of the cost of follow-up care or rehabilitation related to the procedure.  May use any of the following: the average billed-rate, average paid-rate accepted from private insurers or a cost lower than the paid-rate. As an alternative, the provider may offer a single “bundled” price for care.  Must inform the patient of their responsibilities associated with the care or treatment and the potential for cost variances due to complications that cannot reasonably be anticipated, or that may be due to patient’s health status.  May include any discounts or financial incentives the provider is willing to offer the consumer for choosing the services of the provider.  Must include any quality data that the provider has published related to the procedure or care being provided.  The cost estimate and all appropriate codes or descriptions for the care and course of treatment used in providing the estimate shall be made available to the patient, or the patient’s agent. For a specific course of care that involves regular office or clinical visits over an extended period, the estimate will also contain:  A proposed treatment plan that describes the number and frequency of visits and an estimate of the anticipated cost. If the treatment plan is expected to exceed six months, the provider must, provide a cost estimate and treatment plan for each six month period. Insurer Summary of Coverage If the patient requests from the insurer, a summary of benefits related to the estimate. The summary may be issued in writing, electronically or verbally according to the preference of the insured. The Insurer must provide a good faith summary that includes:  A description of benefits, including restrictions or limitations for out-of-network care related to the estimate, or any charges that may exceed coverage limitations.  Any pre-certification or other requirements that must be completed prior to any care being approved.  An estimated total and type of out-of-pocket costs that may be incurred related to the cost estimate.  The estimated total amount (paid-rate) the insurer anticipates paying the provider related to the estimate. The insurer is not required to disclose proprietary pricing information, but the total amount paid under the summary shall be a reasonably close estimate to the actual amount paid.  Any discounts or incentives the insurer is willing to offer, including incentives for the insured to obtain care from another provider. Provisions for the Uninsured Under current law, an uninsured patient who qualifies for BadgerCare and who enrolls in the program within 90 days after discharge or the first treatment qualify for retroactive coverage. The provider must inform an uninsured patient of their right to obtain such coverage. An uninsured patient who is not eligible for BadgerCare, may enroll in a private insurance plan within 90 days after discharge or the first treatment. The plan must provide coverage for at least 12-months. The provider must accept as payment, the rate the insurer would have paid had the patient been covered at the time, plus any reasonable and customary finance or collection charges. If you would like to be added as a co-sponsor to LRB 0920, please contact the Vukmir office at 6-9180, or the Kanavas Office at 6-9174, or reply to this email by 5:00 pm on Friday, July 24th, 2009.
Read LRB 0920/2