Hospitals Receiving CARES Money Banned from Surprise Billing on COVID-19 Cases

Hospitals accepting money from the massive CARES Act legislation will not be permitted to send patients surprise bills for visits associated with COVID-19, according to ABC News.

It has been widely reported in the past two months that the Trump Administration signed the bipartisan CARES Act legislation to provide relief to American families, workers, and the health care providers on the frontline of the COVID-19 outbreak. In April, the U.S. Department of Health and Human Services announced additional allocations of the CARES Provider Relief Fund to include $100 billion for health care providers including hospitals.

In allocating the funds, the administration sought to address the economic harm across the entire health care system due to the stoppage of elective procedures along with the economic impact on providers incurring additional expenses caring for COVID-19 patients, according to a press release issued by HHS.

The prohibition on surprise billing will protect patients covered by government programs, employer plans, or self-purchased insurance. Hospitals that accept the grants are required to certify that they will not try to collect more money than the patient would have otherwise owed if the medical attention had been provided in-network, ABC News reported.

Below are some additional highlights included in the Provider Relief Fund.

Access to Care

  • President Trump secured commitments from private insurers, including Humana, Cigna, UnitedHealth Group, and the Blue Cross Blue Shield system, to waive cost-sharing payments for treatment related to COVID-19 for plan members.
  • The Families First Coronavirus Response Act, as amended by the CARES Act, requires private insurers to waive an insurance plan member’s cost-sharing payments for COVID-19 testing. The president also secured funding to cover COVID-19 testing for uninsured Americans.

Rural Providers

  • $10 billion was allocated for rural health clinics and hospitals.
  • This money was distributed on the basis of operating expenses, using a methodology that distributes payments proportionately to each facility and clinic.
  • Rural hospitals are more financially exposed to significant declines in revenue or increases in expenses related to COVID-19 than their urban counterparts, HHS reported.


  • A portion of the $100 billion Provider Relief Fund reimbursed health care providers, at Medicare rates, for COVID-related treatment of the uninsured.
  • Every health care provider who has provided treatment for uninsured COVID-19 patients on or after February 4, 2020, can request claims reimbursement through the program and will be reimbursed at Medicare rates, subject to available funding.
  • The government began accepting claims in early May 2020. For more information, visit

High Impact Areas

  • $10 billion was allocated for targeted distribution to hospitals in areas that have been particularly impacted by the COVID-19 outbreak. As an example, hospitals serving COVID-19 patients in New York, which has a high percentage of total confirmed COVID-19 cases, were expected to receive a large share of the funds.


The ABC News story titled, “White House says no ‘surprise’ bills for COVID-19 patients,” may be accessed here:

The HHS press release titled, “HHS Announces Additional Allocations of CARES Act Provider Relief Fund,” may be accessed here:

About Mnet Health

Mnet is the leading RCM & technology provider to the surgical industry delivering white glove patient-pay solutions. Mnet specializes in surgical hospitals, ambulatory surgery centers, and management companies.  As of 2020, Mnet is servicing more than 700 surgical facilities nationwide, both directly and in support of centralized billing offices.  Mnet’s patient-pay solutions significantly increase self-pay collections while creating a better financial experience for patients.

Have a question? Contact Us Now

Physician Practice Patterns Changing As a Result of COVID-19

The COVID-19 crisis presented our society with a host of unexpected challenges and changes that could impact the way we interact with co-workers, family members – and doctors.

Consider this, a survey of physicians conducted at the height of the COVID-19 crisis found that nearly half of its respondents (48%) were treating patients via telemedicine. This figure is up from 18% in 2018, according to a press release issued by study authors Merritt Hawkins, a physician search firm and an AMN Healthcare company, and the Physicians Foundation, a nonprofit advancing the work of physicians.

Other findings from the survey include:

  • 38% of physicians are seeing COVID-19 patients
  • 60% of physicians who are not seeing COVID-19 patients are willing to do so
  • 21% of physicians have been furloughed or experienced a pay cut
  • 14% of respondents plan to change practice settings as a result of COVID-19
  • 18% plan to retire, temporarily close their practices, or opt-out of patient care
  • 30% who are treating COVID-19 patients are feeling great stress but will continue to see patients

Meanwhile, about one-third of physicians (32%) indicated that they will change practice settings, leave patient care roles, temporarily shut their practices, or retire in response to COVID-19. This should be of particular concern to hospitals and other health care organizations already struggling with physician shortages and turnover, according to Travis Singleton, Executive Vice President of Merritt Hawkins.

“Once the pandemic has been contained there will be a backlog of procedures and pervasive COVID-19 testing. Physician re-engagement and retention will be of even more importance,” Singleton said.

“Even prior to the COVID-19 pandemic, physicians were expressing dissatisfaction in their jobs and experiencing high rates of burnout and mental health issues caused by stressors like regulatory burdens and EHR [electronic health record] use,” said Gary Price M.D., president of The Physicians Foundation. “The pandemic is straining physicians further and we need to prioritize providing solutions that will ease the financial and emotional burdens they are feeling as a means to improve their wellbeing now and after the crisis is resolved.  It is the least we can do for the health care workers who are risking their lives to take care of everyone else.”

A positive takeaway of the survey is, of the physicians who are currently not treating COVID-19 patients, 60% are willing to do so and one-third (34%) have more time due to the decline in office visits resulting from the pandemic.

Survey data is based on responses from 842 physicians across the country and the survey has a margin of error rate of +/- 3.5%. Further information about the survey can be accessed at or


The press release may be accessed here:

About Mnet Health

Mnet is the leading RCM & technology provider to the surgical industry delivering white glove patient-pay solutions. Mnet specializes in surgical hospitals, ambulatory surgery centers, and management companies.  As of 2020, Mnet is servicing more than 700 surgical facilities nationwide, both directly and in support of centralized billing offices.  Mnet’s patient-pay solutions significantly increase self-pay collections while creating a better financial experience for patients.

Have a question? Contact Us Now

Blind Spots

By now, most collection agencies working in the health care space are aware of Section 501(r) financial assistance policy requirements for tax-exempt charitable hospitals organized under section 501(c)(3) of the U.S. Code.

While these regulations have been in place for some time and have not been amended since their enactment, it’s always beneficial to review your compliance procedures to ensure there are no gaps or potential blind spots. Likewise, for those thinking of entering the health care accounts receivable market, it can be crucial to understand these requirements in order to attract potential clients and reassure them about your operations.

The Affordable Care Act, enacted in 2010, added section 501(r) to the Internal Revenue Code with the intent of encouraging hospitals to devote more resources to charity care. In 2014, the IRS and the U.S. Treasury issued final regulations implementing the provisions of section 501(r).

Section 501(r) applies to charitable “hospital organizations” that assert the provision of hospital care as the basis for their tax-exempt status under section 501(c)(3). The IRS’s implementing regulations impose four requirements on these hospital organizations: (1) a community health needs assessment; (2) a written financial assistance and emergency medical care policy; (3) a limitation on charges; and (4) a limitation on certain collection actions.

Collection agencies and debt buyers need to pay attention to the billing and collection requirements imposed by the regulations, as well as the notification requirements relating to the hospital’s’ financial assistance policies (FAP).

Under the billing and collection requirements, hospitals must make “reasonable efforts” to determine a patient’s eligibility under the FAP before engaging in “extraordinary collection actions” (ECAs) against that individual. This prohibition extends not only to the ECAs against the patient, but also against “any other individual who has accepted or is required to accept responsibility for the [patient’s] care.”

Under the regulations, a hospital will be deemed to have engaged in an ECA if any purchaser of the individual’s debt, any debt collection agency, any other party to which the hospital facility has referred the individual’s debt, or any substantially related entity has engaged in such an ECA.

ECAs include activities that require a legal or judicial process. For example:

• Placing a lien on an individual’s property;
• Foreclosing on an individual’s real property;
• Attaching or seizing an individual’s bank account or other personal property;
• Commencing a civil action against an individual;
• Causing an individual’s arrest;
• Causing an individual to be subject to a writ of body attachment, and Garnishing an individual’s wages.

As set forth in 26 CFR Section 1.501(r)-6, ECAs do not include: (1) certain debt sales; (2) liens on certain judgments, settlements, or compromises; and (3) claims filed in a bankruptcy proceeding.

Before pursuing an ECA, a hospital must make “reasonable efforts” to notify the individual about the hospital’s FAP. Additionally, a hospital must wait 120 days before initiating an ECA against a patient whose FAP-eligibility is undetermined.

The regulations also provide a 240day period, during which a hospital facility is required to process any application submitted by the individual. While the requirements to notify patients of the FAP prior to taking an ECA ultimately apply to the hospital, collection agencies that contract with hospitals may have an obligation to meet these regulatory requirements.

And while neither the statute nor the regulations provides for a private right of action for violations, a failure to comply can jeopardize the tax-exempt status of the hospital, potentially raise liability related to the loss of that tax-exempt status, and spoil the debt collector or debt purchaser’s relationship with the hospital. As a result, both hospitals and their agents must understand the regulations.

Fortunately, ACA International members have access to SearchPoint document #6248, “501(r) Final Regulations for Charitable Hospitals,” which our compliance analysts have recently updated with new case law. It’s always beneficial to work with your charitable hospital clients to periodically review any collection and billing policies to ensure procedures are being followed by the hospital and agency.

U.S. Chamber Publishes COVID-19 Loan Guide to Help Small Businesses

During the height of the COVID-19 pandemic, the U.S. Chamber of Commerce created a guide to help small businesses, independent contractors and other related business personnel prepare to file for a coronavirus relief loan under the Coronavirus Aid, Relief, and Economic Security (CARES) Act, according to a press release issued by the Washington, D.C.-based organization.

The U.S. Chamber’s Coronavirus Small Business Guide (available at outlines the steps small businesses should take to prepare to access much-needed funds to help keep their workers on the payroll during this disruptive period. Further guides will be developed as the CARES Act is implemented.

“The U.S. Chamber of Commerce is working with state and local chambers across the country to provide businesses with the information they need to stay afloat and keep people employed during the pandemic,” said Suzanne Clark, president of the U.S. Chamber of Commerce. “This comprehensive guide ensures small business owners fully understand what aid is available to them and how to access those funds as quickly as possible. We remain committed to ensuring no family or business goes bankrupt due to financial hardships associated with the coronavirus.”

Additionally, to help small businesses, the U.S. Chamber of Commerce compiled an interactive map to show the aid available to the public on a state-by-state basis (click here for additional information).

In March, Congress passed the CARES Act which allocated $350 billion to help small businesses keep workers employed amid the pandemic and economic downturn. Known as the Paycheck Protection Program, the initiative provides 100 percent federally guaranteed loans to small businesses that maintain their payroll during this emergency. Furthermore, these loans may be forgiven if borrowers maintain their payroll during the crisis.

The U.S. Small Business Administration posted additional guidance ( about the Paycheck Protection Program to its website in April, including a sample application.

HHS Resolves 99% of HIPAA Related Complaints

Since the compliance date of the Privacy Rule in April 2003, the U.S. Department of Health and Human Services Office of Civil Rights (OCR) received over 225,378 Health Insurance Portability and Accountability Act (HIPAA) complaints and initiated over 993 compliance reviews.

As of Dec. 31, 2019, the office resolved 99% (222,175) of cases. More than 27,600 cases were resolved by requiring changes in privacy practices and corrective actions by or providing technical assistance to HIPAA covered entities and their business associates. OCR settled or imposed a civil money penalty in 73 cases resulting in a total dollar amount of $111,855,582.00.

Various types of entities have been investigated to include national pharmacy chains, major medical centers, group health plans, hospital chains, and small provider offices. In another 12,094 cases, OCR investigations found that a violation had not occurred. Additionally, in 40,882 cases, OCR intervened early and provided technical assistance to HIPAA covered entities, their business associates, and individuals exercising their rights under the Privacy Rule, without the need for an investigation.

In the remainder of the cases (141,595), OCR determined that the complaint did not present an eligible case for enforcement. These include cases in which:

  • OCR lacks jurisdiction under HIPAA. For example, in cases alleging a violation by an entity not covered by HIPAA;
  • The complaint is untimely, or withdrawn by the filer; and
  • The activity described does not violate the HIPAA Rules. For HIPAA VIOLATIONSHHS Resolves about 99% HIPAA-Related ComplaintsHealth plans are among the least likely entities to violate the rule. For example, in cases where the covered entity has disclosed protected health information in circumstances in which the Privacy Rule permits such a disclosure.
  • From the compliance date to the present, the compliance issues most often alleged in complaints are, compiled cumulatively, in order of frequency:
  • Impermissible uses and disclosures of protected health information;
  • Lack of safeguards of protected health information;
  • Lack of patient access to their protected health information;
  • Lack of administrative safeguards of electronically protected health information; and
  • Use or disclosure of more than the minimum necessary protected health information.

The most common types of covered entities that have been alleged to have committed violations are, in order of frequency:

  • General Hospitals;
  • Private Practices and Physicians;
  • Outpatient Facilities;
  • Pharmacies; and
  • Health Plans (group health plans and health insurance issuers).
  • Referrals

OCR refers to the Department of Justice (DOJ) for criminal investigation appropriate cases involving the knowing disclosure or obtaining of protected health information in violation of the Rules. For additional information, click here:

News & Notes

Texas Makes it Easy

The Texas Medical Association (TMA) produced a seven-page summary of the surprise-billing law (Senate Bill 1264) passed by the Texas Legislature in 2019. TMA’s overview explains topics such as when the law applies, and how the arbitration process works. The summary is accessible here:

Payback: West Coast Doc Pays Penalties

The California Department of Managed Care (DMHC) settled a lawsuit against Dr. Nancy B. Way, “requiring her to stop illegally balance billing California enrollees,” and to pay $13,000 civil penalties. In response to the action, DMHC Director Shelley Rouillard recommends that consumers check their bills and contact their health plan if they have questions. Additional information may be accessed here:

Congress Eyes Medical Debt in New Legislation

ACA continues to maintain open lines of communications with lawmakers as they consider moving forward with legislation that could impact the way the industry approaches medical debt collections.

House Legislation

In December, the House Financial Services Committee marked-up legislation titled, “Consumer Protections for Medical Debt Collections Act” (H.R. 5330), which would prohibit medical debt reporting for a year, and would ban reporting on debt arising out of “medically necessary procedures.”

Introduced by U.S. Rep. Rashida Tlaib (D-Mich.), the legislation would also prohibit collecting medical debt for two years.  These proposed restrictions would make it difficult for accounts receivable management industry professionals seeking to collect rightfully owed debt while creating a disastrous situation for medical providers caring for patients.

Senate Legislation

Meanwhile, ACA has had numerous discussions with lawmakers in the House and Senate regarding more reasonable delays in credit reporting such as 60 or 180 days—despite potential challenges posed by these delays. The Medical Debt Relief Act, introduced by U.S. Sen. Jeff Merkely (D-Ore.), and co-sponsored by Senators Richard Blumenthal (D-Conn.), Elizabeth Warren (D-Mass.), Bob Menendez (D-N.J.) and Dick Durbin D-Ill.), would prohibit credit reporting for one year.

However, unlike the House bill, the Senate version clarifies that the legislation does not impact when a debt collector may engage in activities to collect or attempt to collect any debt owed or due or asserted to be owed.

ACA’s Efforts

ACA is actively discussing this legislation and the many flaws associated with it, with both Democrats and Republicans, including lawmakers who sit on the House Financial Services Committee and the Senate Banking Committee.

ACA sent a letter opposing the legislation to both the House and Senate last fall and launched a grassroots campaign in early 2020 to allow ACA members to engage directly with their members of Congress about how this legislation would impact them and the medical providers they serve (the letter is accessible on ACA’s advocacy page or here:

ACA is also working closely with other trade associations representing medical providers and credit reporting agencies to ensure that Congress understands the broad impact this issue could have on the ability to provide medical care to consumers, the accuracy of the credit reporting system, and the economy.

As the industry continues to face an unprecedented number of attacks in the 116th Congress, it is critical for ACA to educate lawmakers about flawed policies and to work with the Senate to ensure that House bills such as H.R. 5330 do not move forward in the Senate.

ACA members are encouraged to attend the Washington Insights Fly-In May 19-21, 2019, in Washington, D.C., to discuss this bill and other issues with lawmakers. Watch for updates on the Fly-In!

Trump Extends Comment Period for Proposed Rule on Price Transparency

Two days after Christmas, the Centers for Medicare and Medicaid Services extended the comment period for the “Transparency in Coverage Proposed Rule” published Nov. 27, 2019 by the Department of Health and Human Services, the Department of Labor and the Department of Treasury, a statement from CMS said. The proposed rule delivers on President Trump’s Executive Order on Improving Price and Quality Transparency.

The new comment period deadline was extended to Jan. 29, 2020 in response to public feedback and in consideration of the holiday season. According to the Trump Administration, the proposed rule is “a historic step toward putting health care price information in the hands of consumers, advancing the administration’s goal to ensure consumers are empowered with the information they need to make informed health care decision.”

Additional information may be obtained here:

The State of Reporting

Aside from the Fair Credit Reporting Act—the federal law governing credit reporting practices—state laws can impose additional restrictions on credit reporting. For example, some state laws limit the type of information that may be furnished, require consumer notifications, or restrict the reporting period.

Furnishers of information to consumer reporting agencies (CRAs) should be aware of and comply with any applicable state credit reporting requirements.  Some state laws place restrictions on the reporting of a particular type of debt. For instance, California, Colorado, Minnesota, Texas and Washington are all states that place certain restrictions on credit reporting medical debt.

California prohibits hospitals and its assignees from credit reporting certain patients that lack coverage or have high medical costs for nonpayment at any time prior to 150 days after initial billing. Colorado law prohibits data furnishers from credit reporting medical debts that are only partially paid by insurance, unless the health care provider sends the consumer a written notice that includes particular information, as required by statute, to the person responsible for the debt.

In Minnesota, some health care providers signed a written agreement with the Minnesota attorney general covering issues associated with litigation practices, garnishments, collection agencies and billing the uninsured in relation to attempts to collect medical debt. Texas prohibits consumer reporting agencies from furnishing consumer reports that include debts owed for out-of-network medical services.

Washington requires data furnishers to refrain from furnishing information about medical accounts until at least 180 days after the original obligation was received by the licensee for collection or by assignment.  State laws may require furnishers to provide consumers with a notice of furnishing negative information disclosure prior to, or shortly after, reporting adverse information to a CRA.

For instance, California and Utah require creditors and debt collectors to send consumers a written notice prior to or within 30 days after furnishing negative information concerning the consumer.  Further, state laws restrict when information can be furnished to a CRA.  For instance, Colorado prohibits “[c]ommunicating credit information to a consumer reporting agency earlier than 30 days after the initial notice to the consumer has been mailed, unless the consumer’s last-known address is known to be invalid.

These requirements demonstrate the need for furnishers to review state-specific credit reporting requirements to ensure compliance with credit reporting expectations. For a more in-depth look at state credit reporting laws, ACA members can review ACA SearchPoint™ document #1255, State Credit Reporting Laws.

After 15 Years, New Federal Overtime Rule Advances Salary Thresholds

Accounts receivable management industry companies may want to begin reviewing overtime and scheduling policies as a new overtime rule took effect Jan. 1, 2020.

The new rule, which makes 1.3 million workers eligible for overtime pay, raises the “standard salary level” from the currently enforced level of $455 per week to $684 per week (equivalent to $35,568 per year for a full-year worker), according to a news release from the Department of Labor.

Additional changes in the new rule include:

  • “Raising the total annual compensation requirement for “highly compensated employees” from the currently enforced level of $100,000 per year to $107,432 per year;
  • Allowing employers to use nondiscretionary bonuses and incentive payments (including commissions) paid at least annually to satisfy up to 10% of the standard salary level, in recognition of evolving pay practices; and;
  • Revising the special salary levels for workers in U.S. territories and the motion picture industry.”

Tips for abiding by the rule changes are available through the Department of Labor’s Small Entity Compliance Guide, accessible here:

Additional information may be obtained by accessing the U.S. Department

Court Dismisses TCPA Violation on Text Messages Reportedly Sent Using ATDS

A group of plaintiffs lost their argument in a case based on the ongoing district court debate about the definition of an automatic telephone dialing system (ATDS) and the capacity to randomly or sequentially generate numbers.

According to an article from Drinker Biddle Partner Michael Daly and Associate Vijayasri Aryama, “Court Holds That Text-Messaging System Must Be Able to Randomly or Sequentially Generate Numbers to Qualify as an ATDS,” the Northern District of Illinois entered a summary judgment against the plaintiffs in Smith v. Premier Dermatology “because it found the system at issue was not an ATDS.”

Plaintiffs in the case brought a putative class action against the defendants claiming they used an ATDS to send text messages about medical marketing communications without the consent of their clients’ customers, according to the article.

The plaintiffs based their argument on Marks v. Crunch San Diego after the defendants moved for summary judgment, specifically “to claim the TCPA’s statutory definition would include devices that could not generate random or sequential numbers, but could ‘dial stored numbers automatically,’” Daly and Aryama report.

However, the decision in ACA International v. FCC swayed the court in this case.  “Based on ACA International v. FCC, 885 F.3d 687 (D.C. Cir. 2018), the Smith Court determined that, although ‘[t]here is a certain allure to the conclusion in Marks,’ the 2003 FCC order ‘is no longer binding or in force’ and the TCPA’s statutory definition did not support Plaintiffs’ interpretation of an ATDS,” according to the article.

Ultimately, the court determined the text messages from the defendants did not qualify as a TCPA violation.  Read the complete article here:

Healthcare M & A Volume Declines in Q3

Health care merger and acquisition activity slowed compared with the second quarter, according to a statement released by  The number of deals announced fell 13%, to 408, compared with the previous quarter and was 15% lower than the 478 deals announced in the same quarter in2018.

Combined spending in the third quarter totaled $51.5 billion, down 63% compared with the previous quarter’s extraordinary $139.1 billion. It was 65% greater than the $31.1 billion reported in the same quarter in 2018, according to

Healthcare technology deals accounted for 33% of the third quarter’s deal volume. The eHealth sector was the busiest, posting 53 deals and making up 13% of the quarter’s total. Year-over-year, eHealth was the only one of the technology sectors to post an increase in deal volume, up 43% compared with the second quarter of 2018.

Combined spending among the technology sectors was more than $31.9 billion, the statement said. Additional information may be obtained here:

SBA Encourages CFPB to Mitigate Rule’s Impact on Small Business

The U.S. Small Business Administration (SBA) Office of Advocacy submitted comments on the Consumer Financial Protection Bureau’s proposed rule for the Fair Debt Collection Practices Act (Regulation F) in line with ACA International’s suggestions on consumer communications and disclosure notices and noting the significant impact it could have on small businesses.

Here are a few top-level comments from the SBA Office of Advocacy:

•     Several provisions of the rule will be particularly difficult for small debt collectors and require consideration of alternative approaches. These include the requirement of compliance with the E-Sign Act for electronic disclosures, the requirement of an itemized validation notice, liability for an attempt to collect a debt that is time-barred and requirements for retention of records.
•     The initial regulatory flexibility analysis states that larger collectors may already have some of the proposed provisions in place. The small debt collectors may not. Some of the provisions may require expensive changes to technology and additional training. Advocacy encouraged the bureau to give small entities additional time to comply if they cannot be exempted from the requirements of the proposed rule.
•     The bureau is prescribing the rules pursuant to its authority under the FDCPA, as well as the Dodd-Frank Act’s prohibitions on unfair, deceptive or abusive acts or practices (UDAAP). The UDAAP provisions create uncertainty for first-party creditors who are not supposed to be regulated by the proposal. Advocacy encouraged the bureau to limit the rule to the FDCPA.
•     The rule imposes a limit on the frequency of debt collection calls and provides a safe harbor for debt collectors who comply with the call caps. Because small entities do not usually make calls that exceed the limits in the proposal, Advocacy encouraged the bureau to exempt small debt collectors from the call limit caps.

The SBA Office of Advocacy’s comment letter and fact sheet may be accessed on the SBA’s website at or here Additionally, ACA International submitted a 154-page comment letter available on its website at

Trump Executive Order Opens Door for Hospital Price Transparency

The Centers for Medicare & Medicaid Services in July proposed a rule that would require hospitals to make pricing information publicly available. It is CMS’s position that the rule would increase competition by enabling patients to shop for health care that meets their needs and budgets.

The proposed rule follows President Donald Trump’s June Executive Order that “lays the foundation for a patient-driven health care system,” according to a press release issued by CMS. Trump’s executive order states, “Opaque pricing structures may benefit powerful special interest groups, such as large hospitals and insurance companies, but they generally leave patients and taxpayers worse off than would a more transparent system.”

Indeed, a statement released by Alex Azar, secretary of U.S. Department of Health and Human Services, noted that “healthcare leaders across the political spectrum have been talking about this need for real transparency for years. This proposal is now the most significant step any president has ever taken to deliver transparency and put patients in control of their care.”

The proposals for calendar year 2020 include changes that would require hospitals to take the following actions:

• Make public “standard charges” for all items and services provided by the hospital.
• Publish standard charges on the internet in a machine-readable file that includes common billing or accounting codes and a description of the item or service. This provides a common framework for comparing standard charges from hospital to hospital.
• Publish payer-specific negotiated charges for common shoppable services (e.g., x-rays, outpatient visits).

To ensure that hospitals comply with the requirements, the rule proposes new enforcement tools including monitoring, auditing, corrective action plans and civil monetary penalties of $300 per day. Additional information, including a list of public comments submitted, may be found on the federal register website at or (, comments were due Sept. 27, 2019) or at CMS’s website at

To read President Trump’s executive order, visit and search for “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.”

Poll Shows a Majority of Americans Worry About Hackers

Given the constant news about data breaches that compromise personal information, it is no wonder that Americans are increasingly squeamish about being hacked. A new poll conducted by POLITICO and the Harvard T.H. Chan School of Public Health found that a majority of American adults worry about hackers gaining access to their Social Security number and credit card information.

When asked about which institutions they trust to protect their personal information, health care organizations such as doctor’s offices and hospitals ranked high, while most poll respondents expressed little trust that internet search engines and social media companies would keep their information safe, the study titled “Americans’ Views on Data Privacy & E-Cigarettes,” said.

More than half of adults said they were very concerned that unauthorized people may gain access to their Social Security number (63%) or their credit card number (57%). Among users of social media, 13% said they were very concerned that content they have posted on sites like Facebook, Twitter or Instagram in the past may come back to harm or embarrass them in the future, and 14% were somewhat concerned.

The poll also asked a series of questions about data privacy as it applies to health information or products that adults may have searched for privately online. Among adults who said they have searched for health information or health products online, 30% were very concerned that a company would use their search information to try to sell them medical products or treatments.

More than a quarter (28%) said they were very concerned such information may make it harder for them to get medical care, and one in four (25%) said they were very concerned that private search information may come back to hurt their chances of getting a job or health insurance, according to the study report.

Many Americans do not just search for health information online; they also obtain personal health information through patient portals. These secure websites give patients 24-hour access to their health information from anywhere in the world with an internet connection. The poll found that about a quarter (23%) of adults have ever set up a patient portal.

When asked what they use their patient portal for, the vast majority (81%) of adults said say they used theirs to see test results. More than half (59%) have used it to schedule an appointment, while 42% had requested a prescription refill and 40% received advice about a health problem using their patient portals. The study also showed that most respondents did not express a great deal of concern about potential hacking of patient portals.
About one in four (26%) patient portal users said they were very concerned that unauthorized people may be able to gain access to the private information contained in their portal. Meanwhile, 15% of users said they were not concerned about such a scenario at all.

The State of Medical Collections

Medical debt accounts for one of the largest markets in collections.  While the Fair Debt Collection Practices Act regulates debt collection in general, the American Hospital Association (AHA), the national organization that represents and serves hospitals, health care networks and their patients, created a set of guidelines for member hospitals to follow regarding their billing and collection practices.

Other state hospital associations have implemented their own guidelines as well. ACA members who collect medical debt should be aware of both state and federal guidelines for hospital billing and collections.  The guidelines introduced by AHA include several objectives member hospitals are to set into practice to better serve their patients. The guidelines include substantive criteria under the following headlines:

  • Communicating Effectively
  • Helping Patients Qualify for Coverage
  • Ensuring Hospital Policies are Applied Accurately and Consistently
  • Making Care More Affordable for Patients with Limited Means
  • Ensuring Fair Billing and Collection Practices

In addition to the AHA guidelines, state hospital associations have adopted their own guidelines for their members to follow. While the state association guidelines tend to mirror those of the AHA, each has added its own specific language or requirements. Not to be left out, some states have even enacted legislation governing hospital billing practices.

A few states have robust legislation concerning hospital billing. One state’s hospital billing act requires each hospital in the state to establish a written policy about when and under whose authority patient debt is advanced for recovery efforts.

Any debt collectors who contract with the hospital must follow its policy. Among other things, debt collectors in this particular state must have a written agreement with the hospital for which they are collecting.  The law also limits the ability of the hospital and its agents to use wage garnishments or liens on primary residences as a means of collecting unpaid hospital bills.  Other states with hospital billing requirements are not as robust as the one previously mentioned.

These states have requirements that can include things such as giving notice to the patient as to whether the hospital deems her to be insured or uninsured, and the reason for such determination; not employing a third-party to use physical or legal means to compel the patient or responsible party to appear in court; and not furnishing a negative consumer report or filing suit until 120 days have passed.

It’s imperative that debt collectors who collect medical debt ensure they are aware of the state laws concerning hospital billing. ACA SearchPoint document #2805, State Hospital Billing and Collection Practices, provides an analysis of state and federal laws that deal with state medical billing and collection practices.

Texas Enacts Healthcare Measures Impacting Credit Reporting and Surprise Medical Billing

The state of Texas recently enacted new healthcare measures related to medical billing and credit reporting of out-of-network care. While neither of the bills are specifically targeted at collection agencies, there are some implications regarding the billing of consumers for out-of-network care as well as the reporting of debts related to out-of-network care.

Senate Bill 1037 prohibits a consumer reporting agency from furnishing consumer report information related to “a collection account with a medical industry code, if the consumer was covered by a health benefit plan at the time of the event giving rise to the collection and the collection is for an outstanding balance, after copayments, deductibles, and coinsurance, owed to an emergency care provider or a facility-based provider for an out-of-network benefit claim. . .”

Though the bill does not technically prohibit a data furnisher from reporting debts arising from out-of-network care, debt collector’s may nevertheless want to consider refraining from reporting such debts in order to avoid claims by devious consumer attorneys that even furnishing such information to a CRA violates the FDCPA or state law. Senate Bill 1037 is effective immediately.

Senate Bill 1246 prohibits a nonnetwork physician, provider “or a person asserting a claim as an agent” from billing a patient covered out of network and receiving emergency care in any amount greater than the patient’s responsibility under the patient’s health care plan, including applicable copayment, coinsurance, or deductible.

The new law also requires a health maintenance organization to provide written notice of billing prohibitions in each explanation of benefits provided to an enrollee or physician or provider in connection with a health care service that is subject to the prohibitions. Notably, the bill allows the attorney general to bring a civil action against any individual or entity believed to be violating a law prohibiting balance billing. Senate Bill 1246 takes effect on Sept. 1, 2019.

Other Debt Collection Measures

ACA members should also be aware that Texas recently enacted House Bill 996, which requires certain notices to be provided when collecting debts that are beyond the applicable state statute of limitations. Bill 996 takes effect on Sept. 1, 2019.

For more information on those requirements, members can review ACA SearchPoint #1119, Statute of Limitations:

Collecting Out-of-Statute Debts.  ACA recommends members review these measures with clients and their own legal counsel to determine if any changes are required to current billing or credit reporting practices.

To track legislation in Texas, visit

JAMA Study Finds 36% of Virginia Hospitals Garnishing Wages Over Unpaid Bills

Not every hospital sues over unpaid bills, but a few sue a lot, according to an article published by NPR.  While admitting there “are no good national data on the practice,” NPR writer Selena Simmons-Duffin notes journalists have reported on hospitals suing patients all over the United States– from North Carolina to Nebraska to a hospital in Missouri that sued 6,000 patients over a four-year period.

Simmons-Duffin’s article titled, “When Hospitals Sue for Unpaid Bills, It Can be ‘Ruinous’ for Patients,” focuses on a study published by JAMAThe Journal ofAmerican Medical Association that looks into 2017 Virginia court records on completed warrant-in-debt lawsuits filed by hospitals resulting in garnishment of a patient’s wages.

The JAMA study, led by Martin A. Makary, MD, MPH, of Johns Hopkins University in Baltimore, identified 20,054 warrant-in-debt lawsuits and 9,232 garnishment cases in 2017. Garnishing was conducted by 48 of 135 Virginia hospitals (36%), of which 71% were nonprofit and 75% urban, compared with 53% nonprofit and 91% urban among hospitals that did not garnish, according to the study titled, “Prevalence and Characteristics of Virginia Hospitals Suing Patients and Garnishing Wages for Unpaid Medical Bills.”

“Thirty-six percent of Virginia hospitals garnished wages in 2017, with a small number of hospitals accounting for most cases,” the Johns Hopkins researcher said. “Some characteristics suggest that hospitals with greater financial need (nonprofit, lower annual gross revenue) may be pursuing debt collection to the final stage of garnishment.”

The most common employers of those having wages garnished were Walmart, Wells Fargo, Amazon and Lowes, accounting for 8% of patients whose wages were garnished, the study said. This point was central to Simmons-Duffin’s article, which focused heavily on Mary Washington Hospital, a Fredericksburg, Va.-based hospital that’s part of the Mary Washington Healthcare network. (The JAMA study found that five hospitals accounted for more than half of the lawsuits, with Mary Washington suing the most.)

In response to NPR’s report, Mary Washington officials noted that lawsuits are rare (less than 1% of their patients go to litigation). Lisa Henry, communications director for the health care system, said: “It’s important to us, as a small community, and a safety net hospital, that we’re doing everything we can for our patients to avoid aggressive collections.”

Mary Washington has a months-long process for trying to reach patients before it takes legal action. “By phone, by mail, by email — any access point we’re given from them when they register.  “Unfortunately, if we don’t hear back from folks or they don’t make a payment we’re assuming that they’re not prepared to pay their bill, so we do issue papers to the court.

Because court records are public, Mary Washington officials noted that they are subject to more scrutiny than hospitals that use collection agencies.  “We’re really unclear as to why Mary Washington Healthcare in particular has become the face of this,” Henry says. “I don’t think we’re alone — all hospitals are struggling with, ‘How do we collect appropriately from our patients to stay open as a safety net hospital?’”

Meanwhile, Makary, the corresponding author on the JAMA study who is also a surgeon at Johns Hopkins, was so “outraged” over Mary Washington’s efforts to recoup unpaid debt that he formed an advocacy campaign to encourage the hospital to “stop suing low-income patients for bills that they simply can’t afford,” the NPR article stated.

In defense of Mary Washington, Henry noted that most patients who are eligible sign up for financial assistance and payment plans, the article said. According to its website, [Mary Washington Healthcare’s] “not-for-profit status drives us to be the kind of organization that provides care to those in need, regardless of their ability to pay. We provide significant financial assistance.”

Senate Health Committee Votes to Reduce Health Care Costs

Before heading off for the Fourth of July holiday, the Senate Health, Education, Labor and Pensions Committee approved legislation that ends surprise billing, creates more transparency and increases competition to reduce prescription drug costs. The bill, known as the “Lower Health Care Costs Act” was approved in a 20-3 vote.

“Altogether, this legislation will help to lower the cost of health care, which has become a tax on family Budgets and on businesses, on federal and state governments,” said Committee Chairman Lamar Alexander (R-Tenn.).

“A recent Gallup poll found that the cost of health care was the biggest financial problem facing American families. And last July, this committee heard from Dr. Brent James, from the National Academies, who testified that up to half of what the American people spend on health care may be unnecessary.”

Additional information may be viewed on the Committee’s website accessible here:

Unforeseen Out-of-Network Charges Cause Concern Amongst Consumers

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published in June. On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims.

The research also found that when a patient is admitted to the hospital from the emergency room, there’s a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill. “Millions of emergency visits and hospital stays left people with large employer coverage at risk of a surprise bill in 2017,” the authors wrote.

The researchers got their data by analyzing large-employer claims from IBM’s MarketScan Research Databases, which include claims for almost 19 million individuals. Surprise medical bills are top of mind for American patients, with 38% reporting they were “very worried” about unexpected medical bills. Surprise bills don’t just come from the emergency room.

Often, patients will pick an in-network facility and see a provider who works there but isn’t employed by the hospital. These doctors, from outside staffing firms, can charge out-of-network prices. “It’s kind of a built-in problem,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don’t know whether they are being treated by an out-of-network doctor while in a hospital.

“By definition, there are these circumstances where they cannot choose their provider, whether it’s an emergency or it’s [a doctor] who gets brought in and they don’t even meet them face-to-face.” The issue is ripe for a federal solution. Some states have surprise-bill protections in place, but those laws don’t apply to most large-employer plans because the federal government regulates them.

“New York and California have very high rates of surprise bills even though they have some of the strongest state statutes,” Pollitz said. “These data show why federal legislation would matter.” Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw fewer, according to the study. Legislative solutions are being discussed in the White House and Congress.