Transparency on Hospital and Surgery Center Billing Practices

Unethical billing practices can send a message to patients of disrespect and lack of empathy, and lead to suboptimal clinical outcomes and/or the avoidance of needed care. The Leapfrog Group is working to set standards for health systems on ethical billing practices including price transparency, network matching, fair collections, comprehensible and comprehensive invoicing, fair pricing, and proper referral to assistance programs. How does this build trustworthiness? Patients who feel disrespected in the billing process usually feel disrespected by the facilities and the caregivers associated with those bills, whether or not their physician was involved in the billing process directly. Ethical standards in billing practice are thus essential building blocks of trust between caregivers and patients, because patients do not divorce billing practices from the range of services they encounter when seeking health care. Like it or not, billing practices speak for the physician’s view of the patient, and when that voice is unfair, disrespectful, or cruel, trust is the first casualty.

How It Works

Billing practices are critically important to patients and families, and poor practices undermine important patient reassurance that clinicians have their best interests at heart. Surprise billing, suing patients over medical bills they did not agree to, confusing, opaque bills, and lack of transparency about pricing all significantly erode the trust patients and families place in their hospitals. Patients and families expect common cause with their caregivers, but these billing practices can make them adversaries.

Billing practices are so critical to successful patient outcomes that Leapfrog added questions about them to its annual Leapfrog Hospital Survey and Leapfrog ASC Survey. This will inform the public, plans, and employers about quality practices to help with decisionmaking and payment policies. It will be publicly reported beginning in 2022. This includes 11 new questions focused on four key domains of hospital billing: price transparency, network matching, out-of-network services, and billing practices. Not only will this inform the public, but it will inform clinicians themselves about the billing practices undertaken on their behalf that impact patient well-being.

Skills and Competencies

Meeting Leapfrog standards for billing practices relies on skills and competencies in patient communication, including low-literacy communication, at all levels of care delivery and health care administration. Clinicians must be able to be candid about pricing, and financial leadership must be patient-focused in developing bills that are easily discernable and collections practices that reflect the highest ethics and trust.


The issue of pricing opacity and frustrations with health system billing have been major issues in research, media, and public policy. Multiple stakeholder groups approached Leapfrog (including patients, families, and caregivers as well as employers and purchasers), two JAMA opinion pieces have been published in the past year alone (Billing Quality Is Medical Quality and Rebuilding Trust and Relationships in Medical Centers), and bestselling books like New York Times reporter Elizabeth Rosenthal’s An American Sickness and Marty Makary’s The Price We Pay highlight public distrust of billing practices like these, and how they impact patient outcomes and experience. Policymakers have responded. CMS has issued requirements that hospitals publicly report pricing, and Congress included rules against surprise billing in its Covid recovery bill.


There is evidence that high medical prices and poor billing practices reduce public trust in the medical profession, which can result in the avoidance of needed care. “Financial toxicity — the difficulties a patient has related to the cost of medical care — is a medical complication,” Marty Makary explains in Science Daily. “Taking care of a patient means taking care of the whole person.” Patient perception that they cannot afford care or cannot trust providers to give them accurate information in advance of the service has been associated with excess morbidity, such as stroke and complictions from diabetes. It also creates adversarial situations for clinicians that can contribute to burnout.


Leapfrog worked with its research team at Johns Hopkins Medicine to compose the survey questions on billing practices, and that team will work to advise health systems on meeting Leapfrog standards across each of the four domains: price transparency, network matching, out-of-network services, and billing practices. Leapfrog’s survey data is used nationally by employers, health plans, publishers, and others to inform the public about hospitals and ambulatory surgery center quality, and structure value based purchasing arrangements that reward excellence. This information will help shape new standards for transparency and trust in billing practices across the country.