The Mock Claim Proposal: A New Approach to Health Care Cost Transparency

For many patients, understanding the cost of a medical procedure before receiving care can feel like a guessing game, reflecting factors beyond the provider’s role in delivering care. Even with insurance, it’s often unclear how much care will be covered, what portion will be out-of-pocket, and whether additional providers involved in the service will bill separately. The No Surprises Act was designed to address this uncertainty by requiring health plans to provide patients with an Advanced Explanation of Benefits (AEOB) — a personalized estimate of their costs before care is delivered.

Implementing an AEOB is a complex undertaking that requires coordination among multiple providers, health plans and IT systems — many of which were not originally designed to communicate in real-time before care is delivered. This additional coordination has the potential to require additional time and resources for providers and plans. To help address these challenges, the AHA and other stakeholders have proposed a practical and scalable solution: the mock claim proposal.¹

What Is the Mock Claim Proposal? 

The mock claim proposal is built from a simple, yet powerful, idea: use the same electronic format that providers already use to submit insurance claims to transmit good faith estimates to health plans. These estimates would be submitted as “mock claims” — mock versions of real claims not intended for payment, but to estimate the cost of care. This allows health plans to process the mock claims using their existing adjudication systems and generate a consolidated AEOB for the patient.

View the detailed white paper below.