Agreement could signal added requirements for pricing transparency, marketing at urgent cares

Urgent care centers in New York State are being tasked with additional measures to ensure pricing transparency for patients.

New York Attorney General Eric Schneiderman reached agreements with four New York urgent care centers this week to provide detailed information to consumers about health plan participation and in-network versus out-of-network coverage. It’s the first enforcement action of the state’s recently adopted “Surprise Bill Law,” enacted to protect consumers from unexpected medical billings and to help patients make informed choices when selecting a provider.

Alan Ayers, Vice President of Strategic Development at Practice Velocity and a Board Director with the Urgent Care Association of America, said it’s significant for urgent care centers nationwide that a large state is looking at the marketing practices of clinics.

Pricing at urgent care centers, and all medical practices, will come under a spotlight given the trend toward high-deductible insurance plans that make consumers more actively engaged in containing costs for their medical care.

“Urgent care is a retail delivery channel for medicine that’s focused on providing good clinical outcomes and a positive patient experience, such that patients will return to the center and tell others to do likewise,” Ayers said. “Unexpected balances and other surprises in billing, especially weeks after the fact, negate any good experience that might have occurred in the center.”

He added, “urgent care centers should be as transparent as practical in their billing and collections practices, including notifying patients and collecting any financial responsibility at time of service. The reason for doing so, however, is because it makes good business sense and it’s the right thing to do, not because a regulator is watching.”

The New York State agreements require each center to strengthen disclosures and increase notification, including:

• On its website, identify all health plans with which it has contracted to be an in-network participating provider. If the center does not participate with all products that the health plan offers, it shall identify with specificity those insurance products for which it is an in-network, participating provider.
• Post and provide the information in writing to the patient at the time of registration.
• Cease using the term “works with” or “accepts” in relation to a health care plan. Instead, the terms “in-network participating provider” or “out-of-network” will be used.  The centers shall also explain that “out-of-network” will lead to higher charges than in-network services.
• Take steps to ensure the patient does not incur out-of-network costs if the required information is not communicated to the patient.
• Require all health care providers billing at the center to be an in-network participating provider with all health care plans with which the center contracts as an in-network participating provider.
• Disclose to patients the availability of fee information, and, upon request, disclose to the patient the total cost for services that the center will bill the patient.

These bullets seem to constitute a “litmus test” or “road map” for a center to be compliant.

Attorney Geoffrey Cockrell, head of the private equity group at McGuireWoods LLP, contributor to Law360 and author of “The Healthcare Investor” blog, said it’s unlikely similar regulatory actions will be coming down the pike for urgent cares in other states.

“New York is, in general, on the leading edge of regulation,” Cockrell said. “They’re not always the model of what you can expect in other states.”

However, the topic of increased transparency in urgent care center billing could ripple through other areas. Cockrell said officials across the country could look at additional rules or regulations if there’s “uncertainty or opaqueness” around pricing and network affiliations at urgent cares.

Elsewhere, the State of Florida already requires urgent care centers to post their pricing for self-pay patients.  It’s trickier, however, to post each of the contract rates with payers because there are so many variations.

Laurel Stoimenoff, principal at Continuum Health Solutions, LLC, said the issue is complex. Many health plans are limiting access by narrowing their network. And there are so many variations of plans, some that include an urgent care clinic and others that do not.

“There are still times when we cannot get authorization from the insurer, so even if we’re trying to verify coverage the insurer isn’t available.”

Ultimately, Stoimenoff said the responsibility falls to the patient to understand who is in network and who is not under their plan.

“They are the ones who have access to websites as a member. The insurance is an agreement between the member and the insurer,” Stoimenoff said. “While I agree that obfuscation may be a business strategy in some cases – and it shouldn’t be intentionally done – I think this is going to be more challenging for urgent care provides going forward.”