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Medical Practice Price Transparency: Good Business or RICO Violation?


Patients expect more transparency for the cost of their healthcare, but I wonder if sharing my practice's fees and contracted rates will violate RICO.

I would like to tell our patients what we charge and would love to know what our peers charge, but isn’t that a Racketeer Influenced and Corrupt Organizations Act (RICO) violation? I mean, every time I attend a Medical Group Management Association or American Academy of Pediatrics conference, inevitably someone starts saying something like, "For a 99213 we charge…" only to be interrupted by someone else in compliance who reminds the speaker that it’s against the law for doctors to share what they charge. Also, I vaguely remember something about price-fixing in the law course I took while in business school. Either way, sharing what we charge is a big no-no, isn’t it? Did that change while I was distracted by meaningful use? But I digress.

Like many healthcare administrators, I’ve been following the recent hype of the price-transparency debate in both mass media and industry articles. I’ve been surprised that only one or two of the articles mention the possibility that if doctors shared what they charge, prices would go up. It’s simple supply and demand and healthcare is a limited resource; way more demand than supply. Even here in New England, where there is arguably no physician shortage when compared to other parts of the U.S., we still have a short wait list for new patients. If I learned that other doctors in my region charged more, or received more from the payers I deal with, my business school professors would be disappointed if I didn’t raise my fees. After all, I control the limited resource: The doctor.

Sharing my fees might even have a public relations benefit. In my experience, most patients are shocked when they weigh the cost of paying for their child’s annual well exam versus paying for several months of COBRA while they are between jobs. Most of our families, middle- and working-class New Englanders, pay more for the family dog’s healthcare than what we get paid to care for their child. Of course, sharing our fees is complicated when most people have no understanding of medical coding. After all, if it’s a simple cold or ear infection, it’s a 99213. But if it turns out to be a sinus infection or pneumonia it may by a 99214 or even a 99215 if they need multiple interventions, not to mention the codes for X-rays, neb treatments, steroid injections, etc. I’ve always wondered: Is there medical coding in single-payers systems, like in Canada and the UK? I wouldn’t think they need it.

To further complicate the issue of coding, it’s near impossible to explain to the public that even though the federal government sets the coding rules, not all insurance payers have to follow them. So, while patient A has to cover the cost of a 96110 in a deductible, patient B and patient C get off the hook because their insurance providers follow Bright Future guidelines. Just this year, it took me the complete first quarter to figure out the new -25 modifier rule when vaccines are given along with an E&M visit and then it took the better part of the second and third quarters to realize which payers were following the National Correct Coding Initiative edits, which were not, and how to appeal all those erroneous claims (a significant number were lost to timely filing; I simply can’t afford the staff or the technology needed to deal with exceptions to the rules). ICD-10 will kill me.

If you haven’t read it, I highly recommend one of my favorite articles of all time: "A Health Insurance Detective Story," that ran in the New York Times on Dec. 1, 2012. In the piece, the author is trying to decide which insurance plan to choose based on what his out-of-pocket costs will be for an expensive, but critical, medication he needs to control his blood cancer. At the time, the insurance companies were unable to tell him what his cost would be on one plan versus another because, in all their marketing wisdom, they created plans even too complicated for them to figure out. I do hope the Times runs a follow up (if they have and I missed it, please let me know). It’s been a year since that story ran and I’m dying to know if the author was ever able to get an answer. I also want to know: Is the drug he needed covered in Canada? And, if so, for all patients or just patients of a certain age group?

Who has the answer? Can I published my fees and my contracted rates or will I go down for RICO? I’m stumped and I hope someone will please enlighten me.

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