AHA’s Response to CMS’ RFI; Advanced Explanation of Benefits and Good Faith Estimate for Covered Individuals
November 4, 2022
The Honorable Chiquita Brooks-LaSure
Administrator Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
Re: CMS-9900-NC, Request for Information; Advanced Explanation of Benefits and Good Faith Estimate for Covered Individuals
Dear Administrator Brooks-LaSure:
On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations and our clinician partners — including more than 270,000 affiliated physicians, two million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) appreciates the opportunity to provide comments in response to the Centers for Medicare & Medicaid Services’ (CMS) Request for Information (RFI) regarding advanced explanation of benefits (AEOBs) and Good Faith Estimates (GFEs) for covered individuals.
The AHA appreciates CMS efforts to promote greater price transparency and give patients a reasonable expectation of their costs of planned treatment through the issuance of an AEOB to patients prior to care delivery. We support this type of meaningful price transparency that aims to provide patients with reliable, personalized estimates of their out-of-pocket costs, as we believe such policies can help support patients in making informed health care decisions. At the same time, we appreciate that CMS has delayed enforcement of these provisions until a standard industry process for such information exchange can be adopted via regulation to ensure that these estimates can be created as efficiently and accurately as possible.
In order to ensure that the AEOB process is secure and accurate for patients, any CMS technical solution should utilize the existing claims processing framework. The AEOB is created by insurers using GFEs from providers. In this way, the GFEs are essentially a pre-claim that the insurers will use to create an AEOB in the same manner as they use claims post-care to create EOBs. The standard claim transaction is specifically designed to contain and communicate all necessary information in a format that allows health plans to apply edits and adjudication rules to them. These same rules and edits will need to be applied to a GFE in order to ensure that the AEOB closely reflects the patient’s final bill, should no changes to their health care needs occur. In order to ensure that the patient’s AEOB closely reflects the corresponding post-service claim, its creation needs to mirror that of the claim.
In addition, to ensure that all patients have access to the transparency for which the AEOB process was designed, the technical solution must be accessible to all providers. The development of a technologically sophisticated solution with cost-prohibitive implementation fees will not work for the industry, as patients whose providers could not afford to implement the solution would be left without equitable access to cost information. Particularly, the need for additional workforce to sufficiently implement and support a solution using completely new infrastructure could be challenging for many providers amidst the significant and ongoing workforce strain. Although adoption of automated processes varies considerably across different providers, claims submission is performed almost uniformly via standard transaction, with 97% of all claims processed electronically.1 In order to ensure that a standard transaction will be available and useable for all stakeholders, we urge CMS to incorporate the standard claims transaction when establishing an AEOB solution.
In order to assist in your considerations, we provide specific, detailed responses to your questions below. The AHA is pleased to be a resource on these issues and would welcome the opportunity to provide any additional information that would be helpful to the agency. Please feel free to contact me if you have any questions, or have a member of your team contact Ari Levin, AHA’s director of health insurance coverage policy, at firstname.lastname@example.org or Terrence Cunningham, AHA’s director of administrative simplification policy, at email@example.com.
Executive Vice President
Government Relations and Public Policy
View the detailed response below.