WEDI Scrutinizes Price Estimates Citing Concerns Over Accuracy

In a letter the organization expresses concern over information unknown to the provider being used to estimate the cost of care.

Facing strict federal oversight, hospitals and health systems are prioritizing price transparency efforts, making estimation tools and pricing information available and easily accessible to patients. The work is often easier said than done.

In a letter earlier this month, the Workgroup for Electronic Data Interchange (WEDI) offered recommendations to the Department of Health and Human Services over the use of diagnosis codes when providing good faith estimates (GFE):

“Diagnosis, location, and many other variables inform accurate pricing, and this information may not always be known to the degree necessary by the provider to reliably produce an [advanced explanation of benefits] that is accurate enough to satisfy its purpose,” WEDI stated in a letter to HHS.

The organization had the following recommendations:

• Diagnosis codes should be included on the GFE for insured patients when services are scheduled. It is expected that providers will usually know the appropriate diagnosis codes at this point.
• If known, diagnosis codes should be included on the GFE for shopping services. Providers should be encouraged to identify the diagnosis codes when a patient requests a GFE.
• When a request for a GFE is made and the provider cannot determine appropriate diagnosis codes, the GFE can be sent, but the patient should be advised that the AEOB may not be due to the lack of a diagnosis.

It was also recommended that the federal government work alongside providers and shareholders explore whether or not current price transparency tools can be used to meet these needs.

This isn’t the first time price transparency efforts have been under scrutiny by the WEDI. In 2022, the group voiced its concerns over the regulation of good faith estimates and the patient-provider dispute resolution process, noting the former’s potential to increase the administrative burden on hospitals and health systems.

Price transparency has been a cause for concern among providers since the passing of the No Surprises Act in 2022. In April 2023, the Centers for Medicare and Medicaid Services (CMS) announced that noncompliant hospitals would have to complete a corrective action plan, impose earlier civil monetary penalties, and streamline the compliance process.

The number of No Surprises Act disputes continues to soar, with providers blaming insurers for taking advantage of the law.

Lifepoint Health was able to adapt its practices to the new regulations, having developed an internal price transparency team a year before the new rules were implemented.

“The team continues to meet regularly to confirm there have been no changes to the requirements,” Tina Barsallo, vice president of revenue cycle operations, told HealthLeaders. “And the revenue cycle team handles on-going monitoring of the websites and links, as well as the annual refresh.”