A new report is flagging several Hampton Roads hospitals that publish pricing files that passed the federal validator but still leave users unable to calculate some negotiated insurance rates.
PatientRightsAdvocate.org rated 23 of the 45 Virginia hospitals it reviewed as noncompliant with federal price transparency requirements. Its September report found that some hospitals posted payment formulas without enough information to turn them into dollar amounts.
In Hampton Roads, Sentara Norfolk General Hospital, Bon Secours Maryview Medical Center in Portsmouth and Bon Secours Mary Immaculate Hospital in Newport News were flagged for not posting enough data.
Riverside Regional Medical Center in Newport News was flagged for lack of data and concerns about codes used to identify services.
All four hospitals passed the Centers for Medicare & Medicaid Services’ technical validator, according to the report.
Sentara Health did not respond to a request for comment. Bon Secours Mercy Health rejected the findings.
“The report referenced is inaccurate,” said Bon Secours spokesperson Jenna Green in a written response to WHRO. “Each of our locations has complied with federal requirements, posting standard charges online for consumers.”
The Virginia Hospital & Healthcare Association also disputed the advocacy group’s methodology, saying its interpretation of compliance does not necessarily match federal requirements.
“They’re coming up with their own standards, and then basically saying, ‘Well, by our standards, you’re not in compliance,’” said Julian Walker, vice president of communications.
Walker said hospital pricing involves negotiations with multiple insurance companies, and what patients ultimately pay depends on their individual coverage, including benefits and deductibles.
“It’s never one size fits all because what my insurance pays and what my insurance covers is different from what your insurance pays and covers,” he said.
The report reflects a review of public websites and files from April 29 through May 3, with an emphasis on large health systems. The 45 Virginia hospitals are a sample, not a statewide census, said Ilaria Wheeler, the director of research for PatientRightsAdvocate.org.
“A pricing file is not helpful if it does not contain actual prices,” Wheeler said. “The CMS validator tool doesn't check compliance; it just checks basic form and structure.”
Federal rules that took effect in 2021 require hospitals to publish detailed, machine-readable files of their standard charges, including negotiated insurance rates and discounted cash prices.
Though CMS guidance allows hospitals to post formulas when negotiated rates cannot be expressed as a dollar amount, hospitals must still provide the available information needed to calculate those rates, including relevant fee schedules or components of the formula.
Christopher Whaley, professor of health services, policy and practice at Brown University, said PRA’s reports offer a systematic way to examine whether hospitals’ public files contain usable information.
He said he has relied on earlier editions to inform his own analysis of hospital compliance.
“I think that if hospitals have the sophistication to send bills to patients that vary based on the insurance company, then they should also be able to report prices by insurance companies,” Whaley said.
However, Matthew Fiedler, a senior fellow at the Brookings Institution, said the issue is more complicated than whether a hospital lists a dollar amount.
He said PatientRightsAdvocate.org did “a pretty careful job” reviewing hospital files, though some decisions about whether a file is compliant involve judgment.
In some cases, Fiedler said hospitals could provide clearer formulas or more of the information needed to use them. In others, the underlying contracts with insurers are so complicated that there may be no single price to report in advance.
A hospital may, for example, be paid a daily rate for an inpatient stay. The total depends on how long the patient remains in the hospital. Other contracts may depend on the combination of services delivered during treatment.
“There may be no single dollar amount that is correct for all patients in all situations,” Fiedler said.
He said that complexity also limits what price transparency alone can accomplish. Making prices easier to compare could require changes to how hospitals and insurers structure their contracts, not just more disclosure.
“Healthcare is complex, and as a consequence of that, medical billing is complex, and so you really need a lot of knowledge to understand what these prices are, and that's a big barrier for a lot of people because some people are experts in medical billing, but lots of people aren't,” Fiddler said.
Jennifer Mellor, a professor of economics focusing on health from William & Mary, said another challenge is whether patients can realistically use the pricing information hospitals publish.
“A lot of consumers are probably not going to be downloading the machine-readable files where those algorithms appear,” Mellor said.
Patients may instead turn to hospitals’ online price estimators. But Mellor said they still have to find the tool, know which procedure to search for and identify their insurance plan consistently across different hospital websites.
Insurance can also reduce the incentive to shop. A patient with a fixed copay may have little reason to respond to small differences in hospital prices, while someone in a narrow network may have few providers to choose from.
“The insurance that you have could blunt how sensitive the consumer is to small differences in prices across hospitals,” Mellor said.
Research on earlier price transparency tools has found mixed results on whether patients use them to choose lower-cost providers, she said.
In a statement sent to WHRO, Centers for Medicare & Medicaid Services said it began assessing hospitals under updated rules April 1. For negotiated rates based on formulas or percentages, hospitals must now report historical payment data in dollars, including the median amount.
The agency said it issues warning notices and requests for corrective action plans when it finds deficiencies.
Hospitals that have made no attempt to meet the requirements, such as posting neither a pricing file nor a shoppable-services list or estimator, can be required to submit a corrective action plan immediately, without a warning first.
