Revenue Cycle

Tip: Decide whether to divulge your CDM to a health plan

Patient Financial Services Weekly Advisor, July 15, 2005

More and more health plans are asking hospitals for their chargemaster (CDM). It may be because they want to verify that you haven't increased fees by more than the consumer price index percentage in your contract, or maybe they're making sure that you're not engaging in illegal price fixing with your competitors.

But just because a plan wants your CDM doesn't necessarily mean that it's entitled to it, says Jeff Sconyers, vice president/general counsel at Children's Hospital and Regional Medical Center in Seattle.

To determine whether you're required to hand over your CDM, do the following:

  • Review state law. There's no federal law about this issue, but you need to check whether your state law requires you to divulge your CDM. State law varies widely. For example, California recently passed a Payers' Bill of Rights that requires hospitals to make their CDMs public. The bill also bars hospitals from forcing plans to give up their right to view the hospitals' CDMs. Other states require providers to give itemized bills or explanations of charges to patients, so the obligation is less clear. If this is the case in your state, you have a better argument against handing over your full CDM to a plan. And some states don't address the issue at all.

  • Review your contract. Check whether your contract requires you to give a copy of the CDM to the plan. Contracts often include this requirement, but you may not realize it's there until the plan asks for the CDM, says Sconyers.

    For example, Westbrock's hospital wanted to deny a plan's request for its CDM. But when Westbrock reviewed the contract (signed before he had joined the hospital), he discovered that the plan was entitled annually to an electronic version of the CDM.

    Even if the contract doesn't specify that the plan is entitled to the CDM, you may need to share it with the plan to comply with other contract requirements. For instance, if your reimbursement is based on a percentage of your usual, customary, and reasonable charges, the plan is probably entitled to view your charges to determine whether they're reasonable, says Ken Conner, CPA, partner, Decosimo Corporate Finance in Chattanooga, TN.

    Note: Reasonable is not determined solely by the plan. Before releasing the CDM, ask the plan to provide information concerning their establishment of reasonable and customary. Or if the contract gives the plan the right to access your records during a billing investigation, it can probably argue that your CDM is part of the records that it's entitled to see.

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