Does wondering how Quizzify’s ER Sticker Shock Prevent Consent got invented keep you up at night? If so, reading this article should reduce your Ambien intake.
Presumably by now, you yourself have the “Prevent Consent” language on your phone, as many brokers, consultants and benefits managers do, for their own family's use. And, boy, do they use it. The majority of these testimonials are from benefits advisors and managers. (You'll also notice they tend to be much less shy than employees about going on camera.)
Just in case you don’t have it, it’s:
“Superseding other consents, I consent to responsibility (including insurance) for up to 2x Medicare following receipt of an itemized bill for appropriate treatment coded to the correct level.”
The Prevent Consent turns the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), a law that hospitals use to increase prices for non-elective services, into a law you can use to decrease prices for non-elective services. All the aspects of it are linked from this posting.
Here’s how it got started and has evolved since then.
Reference-Based Pricing (RBP)
Having come from the wellness/disease management industry, where utilization and outcomes measurement are the issues, I was not very familiar with the way pricing worked, to put it mildly. I would like to credit Marilyn Bartlett and David Contorno, who both in person and in writing described it to me well enough that there is now a (customizable) Quizzify employee quiz specifically to teach RBP.
The Price We Pay
I bought Marty Makary’s book as soon as it was published, and not just because Quizzify earned some effusive praise in it (p. 226). I had been following Dr. Makary’s adventures in healthcare for quite some time, and knew The Price We Pay would be a page-turner, which it was/is.
One of main threads was about the financial consent that hospitals want you to sign before they will treat you. Signing their consent basically commits you to pay whatever they want to charge. (The No Surprises Act now takes the edge off that open-ended agreement by curbing out-of-network abuses, but in-network prices for emergency care are so high that “takes the edge off” is all we can hope for.)
Dr. Makary wisely advised not to sign ER consents. For non-elective care, EMTALA requires hospitals to treat ER patients the same, regardless of ability – or, in this case, willingness – to pay. He termed the agreement-to-treat-but-not-agreement-to-pay a “battlefield consent,” meaning “treat me now and we’ll argue about the price later.”
The Original Prevent Consent: Version 1.0
Those three folks were the pioneers. One invented peanut butter, the other chocolate. All Quizzify did was combine them into a Reese Cup. We applied RBP to the "battlefield consent" to write the original version of what is formally known as the ER Sticker Shock Prevent Consent:
I consent to appropriate treatment and to be responsible for reasonable charges up to 2 times the Medicare rate.
This language could be downloaded from the Quizzify website. We also provided a version on clear tape to be affixed to a conventional insurance card. Here is my original:
And while several Quizzify clients gave their employees the tape, which is still available with the updated Consent, a few employers (those with TPAs rather than carriers, and hence had more “hand” in benefits design) had the language printed right on the card.
To answer one of the most common questions, the reasons we benchmark at “2x Medicare” are as follows:
Medicare pays much, much less for non-elective care than commercial payers do. (The difference in reimbursement for elective care is far narrower. Occasionally even less than 1x.)
Our offer must be reasonable enough that a hospital won’t pursue the patient. Medicare is most hospitals’ largest payer, so it would be risky for a single patient to insist on paying the Medicare rate itself. But there is no other magic to that 2x multiple than wanting to discourage hospitals from fighting it.
Medicare’s ER reimbursement is low enough that, even when doubled, the patient’s total bill is guaranteed to be below $1000 in the 48 states.
Version 1.1 and 1.2
Early on, someone gave the ER an insurance card with our Consent taped on it, but also signed the hospital consent. We had not anticipated that someone would do that. The dispute was settled somewhere in the middle since neither side had a good enough case to press it. We then updated the Consent to its current form:
Superseding other consents, I consent to appropriate treatment and to be responsible for reasonable charges up to 2 times the Medicare rate, coded at the correct Level.
We have no idea whether “Superseding other consents” has any legal impact were this situation to arise again. More importantly, neither would the hospital. It just gives the hospital one more unknowable, meaning one more reason to settle on favorable terms, rather than risk a precedent-setting court case that could disrupt their entire pricing structure.
Of course, dueling consents means we can’t 100% guarantee the “settlement on favorable terms” will be for 2x Medicare, as we do when the Consent is used correctly.
As to the last four words in the Consent, there have been multiple situations where patients do get charged the 2x Medicare rate, but the actual visit itself is upcoded, as is increasingly common. Listen carefully, hospitals: a few stitches do not constitute a Level 5 emergency! The rationale for those last four words – adding uncertainty and risk to the hospital’s legal position – is the same as for “Superseding other consents,” with the additional feature that routine upcoding could get the hospital in trouble generally if a light is shined on it.
Version 1.3 and 1.4
As the evolution of our Prevent Consent continued, we found that people needed additional support and advocacy in the ER. Curiously, no conventional “care navigation” or "patient advocacy" companies or other vendors offer this Consent.
We don’t know what could be more mission-critical for care navigation/patient advocacy vendors than actually navigating care and advocating for patients exactly when care needs to be navigated and patients advocated for, but Quizzify2Go is purpose-designed for that role, and we are happy to complement conventional navigation services for our clients to create full navigation/advocacy. For our clients, that's another Reese Cup!
The first level of support we provided was a “Know Your Rights” page below, that can be downloaded (now gated) from www.2go.quizzify.com. For instance, who knew you didn’t have to write in your Social Security number? The hospital collects those to ding your credit if you don’t pay. That’s the only reason.
Version 2.0
We also had many situations where I personally got called basically in the middle of the night (OK, slight exaggeration – I’ve never actually been woken up) with something along the lines of: “Hey, what’s that language again?” And then there was: “I have a friend in the ER right now. Can she call you?”
The latter call was from Jessica Brooks of the Pittsburgh Business Group on Health (PBGH). By some measures, PBGH is the #1 regional group in the country. Meaning that Jessica Brooks is the EF Hutton of regional business group leaders.
So I listened. Especially after that call – and it took more than a year to work out the details, with the help of Ault Medical Management and uber-healthcare attorney Doug Aldeen – we now staff a 24/7 line to support patients on the spot by talking to the ER intake person directly in the event of hesitation. Telling the latter that “This call is being recorded” encourages them to understand EMTALA requirements. Seems that virtually all are familiar with EMTALA, once the recording app is activated.
And those of you who had no idea why this scene was funny, well, now you know:
Version 3.0
We found that many employees who had access to the Consent forgot about it between open enrollment and their ER visit. At open enrollment, who pays attention to a discussion of something they don’t anticipate ever needing? So we took on a major project to dramatically enhance the scope of the Consent, by giving employees many more reasons to use it.
Specifically, we added 100 sets of questions-to-ask-the-doctor for various ailments/conditions, procedures, tests and drugs. The average person visits or calls a doctor or dentist six times over the course of a year. Each use of Quizzify2Go to guide a conversation reminds the employee that Quizzify2Go is available for emergencies too. We now also urge our customers to take many other steps to ensure usage, and assist in that regard.
Here is a screenshot of. brief excerpt. You can access these from your phone or PC with one of more than 1000 keywords:
Click on, for example, antibiotics, and you'll get a sentence on the most important concern, a set of questions, a link to a Quizzify quiz on antibiotics, other links, a calendaring feature, and the opportunity to email this to a friend-or-relation:
Version 4.0
The most current Version includes a repricing service, reachable from the app. This is very useful because about 10% to 20% of the time, the hospital “forgets” that it accepted the Consent, and sends an old-fashioned bill with lots of itemized charges and many digits in the total amount claimed to be due. We now take care of the repricing and any follow-up correspondence with the hospital to ensure that the correct bill is sent.
Quizzify2Go – both the ER Consent and Doctor “Crib Sheet” components – is largely built out, with only incremental enhancements to follow the dramatic advances that took place in 2021.
We encourage clients and non-clients alike to propose additional enhancements. In the case of the latter, we will ungate the Consent for your group if the enhancement is worthwhile enough for us to pursue.
Meanwhile, to get a sense of what Quizzify is all about, here is our corporate video. Just to set expectations low enough that we can easily exceed them, this is the second-best vendor video ever produced: