Simon C Mathews, MD, and Martin A Makary, MD, MPH, of the Johns Hopkins University School of Medicine in Baltimore, Maryland, proposed a series of metrics for assessing the quality of medical billing practices in a viewpoint article published in JAMA.

According to a 2018 study of 1000 patients, 64% of patients surveyed reported that they had avoided seeking medical care in the past year due to projected costs. Opaque and outdated billing practices compound this issue as many hospitals do not supply an up-front cost and some increase the price if complications occur. Wide variation also exists in collection practices. While some hospitals offer payment plans, others invest in litigation. In 2017, more than 20,000 lawsuits were filed in Virginia against patients over medical debt and 36% of Virginia hospitals reported garnishing the wages of patients with unpaid bills. To reduce this type of litigation in the medical field and avoid significant financial burdens for patients, the viewpoint authors proposed a series of 5 possible quality assessment metrics for hospital billing procedures.

1. Itemized bills – the consistent use of itemized bills in plain English

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2.  Price transparency – the provision of real prices for patients, when requested

3. Service quality – the availability of a billing representative and transparency of the billing process

4.  Suing patients – whether or not the institution sues patients for medical bills

5. Surprise bills – whether or not out-of-network patients are required to pay more than the reference price and whether or not patients are required to pay for complications that occur

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Financial harm is inextricable from clinical harm, the viewpoint authors wrote. The costs of medical care can prohibit the ill from seeking care and precipitate poorer outcomes in individuals who cannot afford it. The authors cited the Centers for Medicare & Medicaid Services, Leapfrog Group, and US News as existing organizations that seek to improve price transparency for patients. Concerted efforts to improve billing procedures will have valuable effects on patient care, as well as hospital performance, they wrote.


Mathews SC, Makary MA. Billing quality is medical quality. JAMA. 2020;323(5):409-410.