Health advocacy group sues AMA to make billing codes public

Dive Brief:

• A patient advocacy group is going up against the most powerful doctor’s association in the U.S. in a bid to wrest away its ownership of U.S. medical codes and release them into the public domain.
• On Thursday, PatientRightsAdvocate.org sued the American Medical Association, challenging its copyright over the current procedural terminology, or CPT, billing code system, which shapes billions of dollars in healthcare payments every year.
• The goal of the lawsuit is to get the codes published online and let the public access them for free, the group, which lobbies for better price transparency in healthcare, said. Currently, the AMA charges licensing fees to retrieve and use CPT codes.

Dive Insight:

The CPT codes provide a standardized way to talk about and bill for medical services, and are deeply ingrained into U.S. healthcare — including in the government, which uses the CPT system to code for healthcare services and procedures in federal programs.

The AMA, which oversees thousands of numerical codes in the CPT system, argues they’re private property.

“Americans should not have to pay a private trade association for permission to see how their medical care is billed and priced. The government made CPT codes part of the operating law of our health care system, but the AMA keeps it behind a paywall and charges patients, doctors, hospitals, health plans, employers, and tech firms for the privilege of understanding it,” Cynthia Fisher, the founder and chairman of Patient Rights Advocate, said in a statement.

“We are asking the court to affirm a basic principle: No one can charge the public to access standards that are incorporated into state and federal law,” Fisher added.

The AMA did not respond to a request for comment.

The medical association has crafted and released CPT codes since the 1960s. But there’s rising discontent among some politicians and healthcare stakeholders about having that much power in the hands of one industry group.

For one, companies that use the codes have to pay license fees, which the AMA says go toward the costs of creating and maintaining the codes. But the association’s monopoly over the CPT system have proved gainful.

The AMA charges providers an annual fee of $82.50 for access to the CPT, along with additional per-user charges. To get a physical copy of the CPT costs $137.89. This revenue stream nets the AMA an estimated $300 million a year.

Last year, Sen. Bill Cassidy, R-La. accused the AMA of being a government-backed monopoly, and chastised the group for charging fees to people who want to use the CPT code set.

And this summer, the CMS solicited comments on alternatives to the CPT system, citing the “longstanding concern expressed over the Federal reliance on a private organization with such an obvious conflict of interest” in its proposed physician payment rule for 2027.