Although hospital price transparency rules Dominates the headlines In the past few months, since the final draft last year, the insurance company-focused version has received little attention. so far.
In the past two weeks, the U.S. Chamber of Commerce and the Medical Care Management Association have filed lawsuits to question the price transparency rules of medical insurance companies. These seem to be the first legal challenge to the rule.
Here are four things to know:
1. Insurer’s price transparency rules
To be completed in late October 2020, The rule requires Payers and self-insurance plans provide personalized information about cost sharing and publicly disclose the rates they pay to providers through online tools. If needed, insurance companies and plans must also provide this information in paper form. The rule aims to control the cost of healthcare.
According to a statement, starting from 2022, payers must publicly release the negotiated rates of providers within the network, historical allowable amounts and billing fees outside the network, and drug pricing information. Health Affairs Blog.
When the rules were finalized, the National Payers Association’s American Health Insurance Program expressed disappointment and stated that the rules would stifle competition and push up healthcare prices.
2. Chamber of Commerce litigation
Through its litigation, Submitted on August 10, The Chamber of Commerce is challenging the specific terms of the rules, which are not consumer-centric, but “reverse, wasteful and illegal.”
Specifically, the lawsuit challenges the part that requires insurance companies to publish internal pricing data in three machine-readable files on the website. The lawsuit alleges that ordinary consumers cannot understand the contents of the document.
For example, the rule requires disclosure of “applicable rates” for all items and services covered by the network plan, with the exception of prescription drugs. However, depending on the lawsuit, the applicable rate for a particular item or service may include different data points, such as negotiated rates, derivative amounts, and base fee schedule rates.
“The requirement for machine-readable documents forced the plan to…disclose large amounts of highly technical pricing data in the form of computer-readable’digital representations,’ rather than simple language intended for individual patients and consumers,” the lawsuit claims.
3. Litigation by the Pharmaceutical Guardianship Association
The National Trade Association representing pharmacy welfare managers, Lawsuit filed on August 12.
The lawsuit challenges part of the price transparency rules, which require plans and issuers to publicly disclose “sensitive data” about prescription drug prices, including the “historical net price” paid after deducting price concessions by drugmakers.
The price of prescription drugs is determined through private negotiation between the drug manufacturer and PBM on behalf of their plan and the issuer’s customers. The price includes discounts offered by pharmacies and manufacturers to improve the treatment of their drugs on the plan formulary-a tiered list of drugs covered by the health plan.
The lawsuit stated: “The entire system depends on the PBM’s ability to effectively negotiate price concessions with drug manufacturers.” “This ability, in turn, depends on the PBM’s ability to conduct meaningful private negotiations.”
Fourth, the purpose of litigation
In these two legal challenges, the plaintiffs hoped that the rules they were targeting Was declared illegal.
In addition, the Chamber of Commerce is seeking injunctive relief to prohibit the defendant from implementing these provisions of the rule.
Photo: Gearstd, Getty Images
