Controversy regarding how not-for-profit hospitals bill, charge and collect from uninsured patients has been around for years, and was raised again this year with reports of aggressive tactics from Accretive Health, a company that sells outsourced billing and collection services to hospitals. Even hospitals' publicizing of financial assistance programs to patients has been shown to be difficult.
A 2009 survey of 99 hospitals conducted by the Access Project and Community Catalyst found little financial assistance policy information available either by phone or on websites. Just 85 hospitals in the survey mentioned the availability of charity care, 42 had an application, 34 had charity-care information in languages other than English and 26 had eligibility criteria.
The ACA sought to address the issues with changes to the tax code, and the Internal Revenue Service released proposed regulations enacting the law's provisions in June.
But several hospital groups disagree with the proposed rules' general approach to enforcing the law. Among those filing letters were the American Hospital Association, the Association of American Medical Colleges and the Healthcare Financial Management Association.
The proposed IRS rules are more restrictive than they need to be to promote the principles sought by the related provisions of the ACA, said Maureen Mudron, deputy general counsel for the AHA. Though the goals of the IRS regulations could be described as transparency and accountability, “they appear to be going for uniformity and detail,” she said.
Similarly, officials for the AAMC and the HFMA believe the proposed requirements are too tightly written. “It is a very prescriptive proposed rule,” said Ivy Baer, senior director of the regulatory and policy group for the AAMC.
The AAMC in its letter pointed to the proposed rule's treatment of a requirement that financial assistance policies be widely publicized as an instance of the rules being too detailed. “Hospitals should be able to devise the optimal methods to publicize their FAPs based on the populations served,” wrote Dr. Joanne Conroy, chief healthcare officer for the AAMC.
The HFMA takes issue with, among other things,z the IRS' estimate that the regulations would take 12 hours of work to comply with; the HFMA estimates 120 to 2,700 hours. “We have greatly different perspectives,” said Rick Gundling, vice president for healthcare financial practices for the group.
Some hospital groups are seeking blanket exemption from the requirement. Hospitals in California would like to receive “deemed status” because of state laws that they say already achieve the goals of the federal law. The National Association of Public Hospitals and Health Systems would like public hospitals to be exempted for similar reasons.
The AHA and two patient advocacy groups take opposite positions on the IRS' proposed methods for calculating the “amount generally billed,” which is the upper limit on what the law says an uninsured patient can be charged. The AHA wants there to be more options than the choices offered: basing it on past rates using either Medicare or a combination of Medicare and private payer rates or basing it on prospective payment rates.
The AHA wrote that the proposed rule's inclusion of Medicare in all the options “departs from legislative history and is impractical and costly.”
But patient advocates Community Catalyst and Families USA would like to see definitions for the amount generally billed based only on Medicare since those rates are the most transparent. “There's a lot of wiggle room in these statutes as to what hospitals can and cannot do,” said Jessica Curtis, Hospital Accountability Project director for Community Catalyst. “It can be sometimes difficult to monitor whether hospitals are complying with the law,” Curtis said.