New Lawsuit Pushes for Greater Transparency in Medical Billing
ALEC’s new Statement of Principles on Healthcare Price Transparency highlights the many areas where further action is needed, such as ensuring automatic price estimates, expanding transparency rules to all providers and facilities, and allowing small and mid-size employers to access their claims data.
A recent lawsuit might pave the way for more transparency and access to medical billing information. PatientRightsAdvocate.Org (PRA) has sued the American Medical Association (AMA), challenging its ability to charge health care providers and patients for access to CPT codes.
The AMA owns the Current Procedural Terminology (CPT) coding system, a standardized language used by health care providers, insurers, and government programs to bill and reimburse of medical services and procedures. These codes are critical to the American health care system. They shape prices, track utilization, and federal and state regulations rely on them.
According to PRA’s press release, federal law and at least 45 states require health care providers, insurers, and physicians to use CPT codes in electronic billing with Medicare, Medicaid, and other government programs. The AMA charges an annual fee of $82.50, plus $18.50 per user, which healthcare providers must pay to comply with the law. Because of this, PRA argues that the AMA’s copyright over the CPT system cannot be enforced.
CPT being referenced by or incorporated into the law doesn’t necessarily mean the copyright is void. However, the 2020 Supreme Court ruling in Georgia v. PublicResource.Org stated that “no one owns the law.” This decision lays out a stronger legal foundation to say that CPT is functionally part of the law since compliance is impossible without it, so it cannot be paywalled.
This is a legal gray area, and the result will depend on many different factors as it goes through the courts. Regardless of how the courts rule, the lawsuit exposes a deeper problem: patients, employers, and payers still struggle to access the basic information needed to understand and compare health care prices.
When patients can see prices before getting care, they’re able to budget for medical costs and choose lower-priced providers when it makes sense. That knowledge doesn’t just help individuals; it will encourage providers to respond to patient decisions. Rather than allowing prices to rise without consequence, providers will have to compete for patients by offering better value and a better price, slowing or even reversing the never-ending price hikes.
The federal and state governments have taken steps to make hospital and insurance pricing more transparent, but there is still much more that can be done. ALEC’s new Statement of Principles on Healthcare Price Transparency highlights the many areas where further action is needed, such as ensuring automatic price estimates, expanding transparency rules to all providers and facilities, and allowing small and mid-size employers to access their claims data.
Whether the courts decide that CPT codes must be freely accessible or not, it’s clear that there is still a large pricing information gap that lawmakers can do more to close. It is essential for patients, employers, and policymakers to have clear, usable pricing information to make better choices for themselves and incentivize lower prices overall.