thank you and may it please the court my name is lisa blat and i represent the hospitals challenging the agency's price disclosure rule which absent this court's intervention will go into effect on january one two thousand and twenty hospitals wholeheartedly agree that patients should know their out of pocket costs for receiving health care but this rule does not achieve that objective and is also invalid st the statute  forecloses the agency's interpretation and nd the rule of violates both the st amendment and the a p a because the rule is unworkable it requires hospitals to misinform their patients and the rule grossly misapprehended compliance burdens record start with the statute a requirement for hospitals to list their standard charges for items and services uninvited us lee refers to the gro charges that appear on hospitals charge masters those are the only default asking prices that universally apply to all payers this was such an obvious conclusion that the agencies though which is i definitely agree the emphasis on the appellate brief is that the interpretation fails step two but i do think it's important that th assuming there is ambiguity that the rule which fails step two and i was just saying i think the step one arguments are important because they certainly do go a long way in undermining the agency's interpretation under step two and it's  with what would you do with the nd phrase including printers in the statute because shortens the government look including it says it says i mean it i so standard standard charges for items and services are limited to gross charges and the including phrase is not being used to loss rate if here because by definition and the government concedes this charges for d are not by definition charges for items and services so this language including language is in here because the items and service language would otherwise exclude it and so the government tries to use that including to say that you can before d r g these tells us we're talking about turned us sure i think that's fair i think though what that this is doing because again we know by definition that it's not an items and services but i we get to the more fundamental problem with the government's reading the government may get you somewhere in saying that that injects ambiguity although we don't think it does but if you go there and say it's ambiguous it doesn't allow the secretary to go to all payer specific negotiated rates and here's why that reference is referring to a non negotiable preset rate by medicare and what the government tries to say is well that creates an ambiguity that allows us to get to on the on the go shaded rates not just the ones that are negotiated for all private payers and rates that have nothing to do with the r g s and so i don't think that helps them but if i could also get that it says the word is the clue to it doesn't say he doesn't say the standard of the statute doesn't say each hospital after doesn't say a list of the hospitals standard charges problems and services provided by the hospital and for that language of a statute that says states include part of rico and that is used the word including and it's use it's not being used a lot strategically it's just doing and contra indication to what the statute might otherwise say but whatever is the problem with the even if you think that there's some ambiguity and there don't you know three problems with trying to say that a standard charge means all pa specific negotiated charge because a standard charge still requires some representative charge and each and every individual e and specifically negotiated rate by definition is not representative it's bespoke is customized it's it's the it's the under ordinary and the customized rate it's just not representative or common ordinary and nd there's no question that this statute requires disclosure of knowable numbers you have to know the number in order to disclose it and many negotiated rates just don't have noble numbers they rather depend on complex algorithms that would vary depending on patient care and that's simply a problem that partner just is never addresses and the rd problem with this and i think this goes back to the step one argument is that this is an unprecedented disclosure regime it really is and it's implausible that congress intended this provision of the affordable care act to usher in a sea change industry practice without anyone noticing and till two thousand and nineteen the agency went through to my king's one in two thousand and fourteen we're going to go back to your statutory charges because most patients are covered under medicare or insurance what is also correct is that the statute was directed to what patients because hospitals would never know that so there's no question the statute can't be talking about patients out of pocket costs because hospitals o s it perfectly reasonable for the government to interpret this statute in such a way that it promotes the maximum amount no it doesn't tell anybody it doesn't tell anybody anything so we can get to that under the a p a but in addition to i mean it we could we could talk about it but just on the negotiated rates but each of those if it really tells no one anything but the one thing we know is it doesn't tell consumers this is supposed to be just the record of what hospitals can disclose that the rate has to again be knowable and many rates are unknowable so already you have a incomplete database and the government will just doesn't address it doesn't speak to it you have no clue what the government thinks about it unless you hear a post hoc representation for the  time in the response rate because the rule doesn't address this the world also is completely silent all rates that are itemized so many rates appear only as a package or a bundle again the rule is completely silent the agency was and in dated with comment after comment saying this is how rates work negotiated rates don't come in these unique i mean way that the government intervention in the rule world doesn't speak to it and in the final their whole entire justification is whatever they say is aren't we doing something well how would you know which agency has never told you how this rule is even workable or could provide any consumer any information if the database is both incomplete and misleading that in the government's brief the st time it says hey hospitals if you have itemized or bundled services like a hip replacement just put and they are not observable in the database so that the hospitals charge that for the st time they still don't have any way of knowing what to do about rates that turn on patient care so they have no clue but they say put an a so there are two problems with that st that is very misleading because it indicates to  consumers that the item is not covered on the insurance plan which turns the purpose of the rule upside down and nd the agency still has to grapple with the problem you can't make this up in your opinion and the government can't get up here in the st time and try to explain how the rules workable that hospitals  never been told and have never had the opportunity to comment actually they commented and then the agency just ignored comments like that also talk about the fundamental argument about what you are saying gets they told that they could at least know something because they could look at it for high deductible plans  least determine assuming incorrectly that you would know something about negotiated rates a good at least look at what's called the discounted cash price so our argument under the both the st member and the a p a this is a very very serious problem government the rule recognizes that requires a discounted cash price that's one dollar of the five definitions of standard charges the rule recognizes that many hospitals just don't have a standardized cashless now they rather ha individual discounts based on sliding scale for financial need and individual charity care and bill forgiveness now what this rule does is it tells hospitals to falsely falsely report that the discounts are cash price is the undiscounted gross price for the service now that conditionally says to uninsured patients that the only way they can get health care is to pay a gross price with the government is going to get up here and tell you what judge taylor you just indicated some inflated price that no one dollar pays so that is just permissions and it's perverse now the government's h h s doesn't dispute this in the rule and you know why because they don't address it they're just silent as to this serious problem even being told by hospital that it would deter patients even care not the government's brief tries to rehabilitate the rule by citing to a different statements i think it's page  the patient counseling well the problem with that is that they block you from putting a corrective statement in the only place that would make sense where you're making the misleading statement so when you have to post gross price for your discounted cash price will in fact that discounts it's in a spreadsheet so it's machine readable and you can't put any disclaimers or long text explanations so you have this very misleading statement saying discounted price equals inflated story text and to the chargemaster sound when it says its hospitals will make public a list of the hospital standard charges are those previously those were the chargemaster charges right so just let me just clear up a little bit so they are there to gross charges and charge master is done you say gross they made they were you were required to list the chargemaster list is that right yet the gross prices are what the charge masters contain so that's your list price madam i got it and those are in your view standard charges is that right yes which was what the obama administr i don't need a modification of this on it assess your client believes those are standard charges so right yes ok now the decision below the district court says the charge master rates are highly inflated often bear little resemblance to the actual payment tended tendered to a hospital by a patient or a rd party provider one study found on average insurers and patients paid only about thirty percent of the amounts and charge master want to make so why wasn't that a violation of the st amendment a violation of the statute if if these are not charges and and that very many people at all pay at gets to your st amendment point the standard is what it gets to the universality of it so no we're not defining standard as maximum i thought you were asking why the gross party being both questions i want to know why the gross charges are  standard under the statute ok and why they are not in violation of the st amendment and your argument that they're misleading so let's take just the statutory are our definition of standard is model  t universe universality and representative the only representative charge only universe and charge is the chargemaster charge not only because it's the maximum because it angers all insurance negotiations so it shows you that if nothing happens in the absence of anyone either in anything the hospitals asking for the less price so it is like your standard recreates or the m s r p or a hotel room rate is the published advertised charge so i think that that's why and if i could just explain i think it gives this in this way why do you think it's important as a commonsense matter that the two thousand and four plan the government has but the government's response to that is that's not the way the hospital business operates greenson one crisis that you think it's a completely different to use menus or you know hotel rates as a model is to miss entirely the way this is here's why a disclosure regime that requires gross charge disclosure is so great so what the government told tells you in the room i think it's at five hundred and forty dollars is that disclosures of gross rates promotes price competition and brings down the cost of patient health care and here's why because it tells the uninsured patient its maximum allowable price and it allows insureds insured patients to comparison shop because when you the starting price is at least somewhat proportional to the ending price you can look at two different hospitals and see that one has a really high gross charge starting asking price and the other one dollar isn't but whatever you think of the word standard the government has no definition of standard charge that doesn't include any price any charge is a standard charge in their view because standard means specific and charge is not limited to the government's asking price so there is no such thing and you can say it's a unique market but you still have to define standard and charge and it can't mean everything particularly when the numbers were unknowable that if i could just get back to the st amendment and just why isn't this misleading again i think that there is some commonsense element to the fact  that two administrations thought that this man that the charge masters and that's what hospitals were doing you know shortly after the passage of the affordable care act in ages you went through two or makings and when the agency went through its nd rulemaking in two thousand and eighteen it never said hey we're proposing negotiated rates it said may be standard but everybody liked a comment whether standard would mean average or median so this wasn't even raised as a possibility either in the two thousand and fourteen or the two thousand it's now why it doesn't violate the st amendment which is a wonderful question so i do think that the passes at think any level of scrutiny that when you have a buyer seller reaction you the government is allowed to prevent the following scenario house but i'm not going to tell you the price and then you say ok and then you list the price so it's always ok for the government to compel you as part of offering a service in a transaction that if you accept here's the maximum price  pay and so i just think that's been a given in st amendment i mean now you know i'm not clear what i mean if you accept i understood that you had to list the chargemaster charges isn't that right or not not just tell a patient after the patients is accepted at the list them right right so what i'm saying is that list just like any west of any price and communicates that if nothing else happens in absence of any other circumstance that's the price you  charged is that what it says those qualifications that you just gave are all those qualifications on the list or is it just the chargemaster list so a chargemaster list is not something that had been published before so this was never this was a big deal when the government in two thousand and fourteen said you've got to do this so it did not come out until two thousand and fourteen and these charge master rates were known to insurance companies but this was why discounted no no no in order to not be misleading that is in order for the patients to not think they're actually going to have to pay the chargemaster rate there has to be some explanation with it and says this is the gross charge otherwise it's going to be misleading right this is a gross charge which may be reduced under certain circumstances or whatever right and i think that's a problem th the government should address now i think all right let's hold on a nd and so with respect to the chargemaster list which you think is ok what's the is there a bunch of kaviak so explain to the patient what it means no but it's remember this statute is not directed at patients this is a ok can i get your that's what i thought you were going to say and therefore i want to know why you think that so it says a list shall make public a list of what wants a point of make public a list if the list is only going to insurance companies so i think what and this is i think a point we were trying to make in the twenty a j letter the government acknowledges that customers are going to read this list that it's don't need being done as a computer spreadsheet database in the hopes that some hypothetical rd party vendor may surface that will then turn this into apps so this entire list that we're talking about with discounted cash i'm trying to read the statute what makes you think that the purpose of the statute was not to communicate information to consumers is there some legist i mean i would have thought when i saw this that this is an effort of transparency with patience maybe not a good effort maybe not a perfect effort maybe not even a constitutional effort but i'm st looking at what the statutory point here is what is the reason for this section so at and by look only at the text and it says public i think that means to tell the public and what the government sad and we don't disagree with i have you think is the answer to this question no i think i think absolutely i agree with the government is that it allows me to comparison shop telling me that if it's not information for the consumer the statute is intended for the consumers that right so this statute is intended for the public which would include the consumers let me be very clear on this the hospitals what i'm saying what the statute is completely directed at is only information the hospitals themselves can disclose which the hospitals can't disclose out of pocket costs it is a very minor point so it gets at the point that no one actually pays and our point is that the statute can't be directed at what people pay because the hospitals will never know that they don't even know what insurance companies will actually pay which the government can see because the actual payment at the end of the day is going to turn on variables about patient care that in terms of a st amendment analysis it is perfectly appropriate for me to stand up here and read to you what the government has said across two administrations which is a good purpose for the disclosure of the chargemaster that it serves a public purpose and i'm not only anneli personally agree with that the hospitals agree with it but it's a fair point as a st amendment matter and as a textile matter that no one has disputed that gross charges absolutely means excuse me standard charges absolutely includes gross charges and that's also in the final will ok i got up at the versa the one thing that i  you want to talk about that and i just have a factual question for you just the fact question which is so is the this two lists right this is shop a bill services list and the comprehensive machine readable list right those are the two lists and you say the statute says the list can't be two is this is just a fact question is is is there anything on the that airlines rates for that their coach is a subset for airline service from washington san francisco is is they have three or four different rates coach is a subset of those rates correct yes but if i could just answer the question this last would say this is a customized thing that the travel agency guys that wrote roads and your hotels your cars and maybe some disney world trips to look at it at sea world so what do you what's the would be the the different let me just to get this out it's different formats with different information to different audiences for different purposes the different information which i think your question goes to is that  delivery or sleep study or some very complicated things with or without code morbidity may not be the way it's described on the shuttle service list doesn't necessarily transform into a straight r now it might be because a straightforward thing like psycho therapy may have you know a machine readable counterpart but the critical part is once you get to the shop or will service last which is this consumer friendly  and every hospital on its own minus a seventy gets to pick any shopper will services that you would dream up ahead of time that you might schedule an advance so it's like oh well let me think about how i might need hospital care and that's not the way the items  services in the arduous works so in that sense i think a sentence making a word out of the alphabet or using a recipe because you have the ingredients on your grocery list but somebody with some intelligence has to figure out how to put all those ingredients together and there's no limit on how you describe your shop will service you can describe i think the government have like i don't have seventeen references to ancillary services with stuff i've never heard out and it said mix and match it's not exhaustive just  what you think might be helpful for consumers and so i think in the government's view that that's just to us it has to be because there's really no other meaning for journalists now so that's i think that's my best our you know  subset i have a question about your i guess it's both your creation and your st amendment on page forty three of your brief you say that the agency failed to grapple with reliance interest in gender by its previous rules the st amendment is grounded in much better arguments than the reliance and so on the reliance interest as an a p a matter it is that from the get go hospitals thought the hospitals were just getting together their charge masters and in terms of that everyone agrees the hospitals are all heartily behind transparency that they invested on a lot of time money and expense in two dollars ways of getting this information to consumers one is the price calculator to all that's the alternative way of complying with the shop will service less so that helps is much more directly related to the problem they they sit down with you and you input your data and it tries to give you based on your plan the information and the nd which i think you know you might have had is that one on one counseling sessions where they sit down with you and say what your insurance you know here's how it's going to work with your doctor both they try to figure it out that and that is an investment so the this is a new regime and we can type this is where the government really messed up the government's rule prolifically says this is just no bit what this information is readily available on your rate sheets and you're already doing it for states so just put that information out there you only need thirty days maybe sixty days to do but then the rule prolifically doubles down on to justify the amounts that this information was at your fingertips and you're already doing it understates now those are manifestly false and the government's never contested it and here's why no statute requires this kind of disclosure there are based on retrospective data information where you may know the rates and then you can sort of calculate it and the nd thing is pos mean all new regulations require require many new regulations require substantial additional investment by regulated parties and here the government seems to have been aware of that i mean maybe not as much as you thought but it did increase dramatically the amount if caught complying with costs and it extended it for a year and it excluded excluded hospitals that already ha all on a noble number nd and many of them exist not itemised so there is no way to put any information in that spreadsheet rd of all as if that is already there still a burden problem because even if there's a noble rate there's an actual itemized rate hospitals don't have the information they have to manually reverse engineer it with clinicians legal staff and poring through contracts trying to figure out how this will work for up to six million six thousand different saying something that would cause me to conclude that neither the chargemaster i'm ready which you prefer nor the government's present scheme is transparent they're equally bad in terms of what they communicate so i'm not i can be very honest with you in saying i'm not buying your argument to the extent that you're making it that the charge master rate is discern ibly more transparent than what the government is proposing especially when you says nothing more than a maximum because in my mind that means the hospital costs can tack any rate on the charge master rate because it's only a maximum  down maybe what you can say anything i don't know how that serves a consumer you're saying well the alternative approach doesn't either but if i'm hearing you correctly your principle objection has nothing to do with worrying about transparency it's just that the government's approach is more burdensome one new and more expensive no neither one is transparent hospital don't like lying to their patients and this rule are you lying to the patients as i heard listen to your argument in suggesting that the charge m r rate is a rate it's not and there's nothing that says as i understand it you can tell me if i'm wrong that alerts the can choose summer when they see that charge master rate that  because any and everything below this is possible we do not want to suggest to you that this is the right is that we can do so yes in the sense that hospitals have done the two things i talked about and states have done a this respect at the initiatives of a possible and that is the price transparency tools that have been developed hospital by hospital and state by state but the answer to your question of both regimes are so hot is a bacon sure rule because the agency it's at its word that it may not be a perfect regime but that congress rationally wanted this information out because the government concluded it would bring down patient care and cause price competition now if you don't buy the government's rush now because in two thousand and nineteen they thought that didn't go far enough that's that's totally fair and that's totally rational but the statute didn't allow them to go this far and what the three problems i talked about under the a p a is that they're workability problem that it forces a misleading statement and then it compels correct speech to correct the speech you don't want to make in the st place and then rd is just the the party problem but the big problem is the work bill the problem whatever answer we're going to hear when she gets up is going to be new to me ok thank you ok thank you but i think you will usually in customarily apply it depending on the category paying patient the agency here looked at the realities of the market for hospital care it looked at the statutory text including the diagnosis related groups laws and it looked at the anyone with that particular insurance provider and likely particular plan i have looked old and i go to a hospital that charges that will usually apply to be have been set in advance their contractually negotiate and it's ignoring the realities of the market for hospital care you are to say that in that circumstance hospitals are going to demand it's charge mr price it's going to demand that again the price that it's negotiated with the insurer and under the current status quo it's not based charge s don't exist they exist they're driving insured patients out of pocket expenses patients don't learn of them prior to care they learn of them when they receive an explanation of benefits for weeks or months after the fact at that point the benefit as a result they're going to be motivated to use this information meaning the evidence the record shows runners that consumers currently are casting about for it information and are so desperate for that information that they take it upon themselves to  crowdsource the information that they find on their explanation of benefits forms manually put them onto websites and hopefully get some when or into these pay or specific negotiated rates that again under the rule hospitals  to address any of the players for someone i might make sure i understand so if if i need to go to the hospital to get my appendix taken out and say i have blue cross  right yes if i if i have to have my kind of i'll go see what the look on this thing you know say ok my out of pocket expenses and simply hospital are less than the georgetown so i'll go there is that that an insurance arrangement where you have a cautionary arrangement here insurers say the insurer pays eighty percent and you pay twenty percent if you look at that there are specific rates you're going to have to some math applying your insurance plan so you might have to take twenty percent of the  earlier who is going to pay for their care people are carrying cash in the hospital has an established such a standardized cash discount price it would report its charge mr price and that's not misleading because of course if you say i want to pay for my care in cash and there's no price roast charge at the charge master charge is the price the hospital would presumably come back to now the idea that that disclosure of that rate would mean that someone would think there is an individualized cash discount rates we now have two responses st of course under the disclosure of just chargemaster rates there is no indication of cash prices at all and so it's unclear how that is any less misleading to consumers than saying a standardized ca that under the current regime so again based on the record before the agency community or reasonably concluded that this was going to meaningfully benefit consumers you can see acknowledge that there are a lot of potential barriers that currently exist complex and some consumers might not be able to perfectly estimate their out of pocket expenses in all circumstances the agency acknowledged this but it nonetheless reasonably concluded that it was a necessary st step to start the bridge to start to bridge the significant down or at least certainly not as much as they could or should and so the agency made accommodations to hospitals who are offering price transparency calculators already them if they said you don't have to satisfy the shuttle services list which is trying to serve the same goals but it's certainly your honor not an answer to say that will some hospitals are doing this voluntarily because again you haven't spoke for the agency it was quite clear that consumers are very frustrated so what's your response to this by this argument about able just she says a statute has a list that is one list this requires two lists and she says in response to my question that it's just not true it's just not accurate to say as you do in your brief that the shop will list is just i think you say in your brief merely another way of describing were portraying the data on the machinery of comprehensive machinery comprehensive for all hospitals items and services there's a separate display of charges for three hundred dollars shuttle services statute gives the secretary was it discretion to specify how hospitals are to make public their list of standard rather there is a difference right so all of the standard charge information that will appear in the chapel service this list is derived from the comprehensive machine readable differences are that in the shuffle services list it has there has to be a the charge so that hospital could know if this is included maybe it's an additional fee in which they would provide the number of the feet or you know amount of the feet what the charge information there your honor is going to be the same information coming from the comprehensive  hospitals have to organize it in a more consumer friendly way and again use plain language all of which again is consistent with the secretary's explicit statutory discretion to specify how hospitals are to make their standard charges and yes the agency gave hospitals very wide discretion in how they organize their shop will services and how they list insular resurfaces and that's because the agency recognize that hospitals have a variety of ways of you know offering their services will bring them together not all hospitals are going to charge the same kind of fees along with the service as others so there's going to be differences here but you know knowing that though those differences looking up hospital be a looking often be seen that there are different   thousands of different negotiated rates and non straightforward clients and that the hospitals calculate rate data by patients so they can't even readily identify the rates that you're asking about and maybe a last argument it's all based on algorithms which you know you'd have to reverse engineer in order that they would have to reverse engineer in order to determine and so  the hospital's estimate of one hundred and fifty hours for a hospital or affecting eleven to twelve thousand dollars one hundred and fifty hours was also the same burden estimate reached by plaintiff's own amicus the health care financial management so so disagree about whether that's every year onwards if you maybe four thousand dollars three thousand dollars lower when you can just put in there it is reasonable because you know a lot of the burden estimate the hospitals are talking about here is the burden of compiling this information in the st instance it's reasonable  point of that display is to allow consumers to you know better engage with this pricing information in a consume we're basing manner of praise estimator tool is going to serve the same purposes and so the agency recognized hate you you the best of your time are about the nd part of the argument that they really can't even do this that they calculate things by patient they can i had benefit of the different rate groupings that they ordinarily build algorithms the cross reference to each one insurer on a per x rate basis then when i get a column in the item in services this would be for x ray and then you would know you know i have negotiate with anthem five hundred dollars for x rays if you haven't negotiated with other then you would say i have negotiated with fifteen thousand dollars for a call and ask if he and you would say it and you wouldn't need to necessarily separately say so i'm trying to describe this in a clear manner in that it's not that the hospital circumstance and they were to report the package as they have negotiated with the insurer and to the extent that hospitals might have to you know manually scour contracts or engage in other kinds of you know compiling efforts between to you know to to sort them out for a year then that's again that's a benefit of their will the agency reasonably conclude that that that that if it serves the statutes folds it's going to benefit consumers and they don't raise the burden on hospitals which again is going to diminish over time after this been done in the st and there are two separate problems the workability problem is separate from the burning problem and i told you i would hear for the st time what her answer to the workability problem was and i have to say i didn't understand it the workability problem is this and the sites are in page nine to ten and twenty five and pay about opening brief page twenty four and twenty six and the hospital's brief are the avalanche of comments sites that dictate this in toto you will look for the role that is not a burden problem the rate exist you just don't know it until the patient showed up for care it could be on a volume discount if you come in for one x rays i understood that that's why you're asked it is two separate questions one how much the whole thing is going to cost and to whether it's doable at all it's not doable at all but i know but she did answer both parts now i take your point to be that she's answering something that you didn't hear before but other than out and that she still hasn't told i still could not tell you how hospital she just says hospitals don't report it i think even though an x ray seems to be a problem and i don't even it doesn't even matter what she says the agency did not speak to this at all the nd thing the agency didn't speak to at all is the problem with the bundled rates and again those rates those things are allowed and they're knowable in advance they just don't exist in the machine spreadable way and she's just wrong the ru requires a number you don't get to put explanations you don't need to put bundled you put a number and they're not in there or you can put in a right or you can put an a which means to me that that is not a service offered the burden that's not what i mean i mean that to you but as i understand her point to be that means you don't have the number available not that the services and offer are not that you don't do x rays but that you don't have a a negotiated charge or cash charge or something like that for and that's fair if the agency wants to explain that which they didn't i don't think you get to make it up on your i understood that perfectly forgetting so i think that's what the words not available normally means that the answer is not available not in the service you think somebody would think if you put an a next to the problem is you have to reverse engineer this has nothing to do with the algorithms or the bundle it's just to just to comply with the rule you have to reverse it and that is pretty good what's missing what give us an example just  talk in generalities about reverse just give us an example so we can understand yes there is a hospital billing works when the patient checks out you called adjudicate the claimant so you enter all the data points and that's the way the hospital billing system is set up and the comments that i'm explaining go through this in excruciating detail so they can plug in and after the fact plan a at inpatient that and location this produces this but what the contract doesn't tell you is what that rate was to start with and there's not a rate sheet which the government kept saying in the rule just look at the rate sheets and the hospital said i don't know what you're talking about there aren't rate she sees are spelled out in contracts in text and we would have to set up vendors but seven times they misstated this is no big deal they end when i ask i'm sorry let me just from just from my own experiences because the silly way i can understand this if i go to the hospital because if you go to the emergency room where your blue cross blue shield doesn't cover everything or maybe doesn't cover it all at the end of the day you get a list of charges from the hospital you are charged x for your x ray your charge y for your visit your charges see for your lab test and each particular kind of lab test a different kind of charge and the next column says how much your insurance company paid for now are you saying that the column the charge for the x ray not the how much insurance covers for it but the charge for the x ray is not a standard to people say even in blue cross patients it's different for every single one recalculated somehow so no couple points that might be at the rate of possible under that plan but to go figure out what that amount was it's not in a rate sheet so you have to figure it out the he had to figure it out after the fact yes that's that's only and i'm asking you did they figure out after the fact because of something about me so that if judge hale went and got the exact same test under the exact same blue cross blue like a lab test for x i don't know for corona virus for example a lab just to take an example which fortunately is not apply to me yeah the lab test is a good one ok or a standard says x ray next column it says charge next column was how much the insurance company paid same same plan same inpatient outpatient same location you might and here's why that doesn't solve any of the  what states are doing with this problem it's not like this is some new mystery what states have asked for because it's not doable what the government wants is after the fact adjudicated claims put that in a database why isn't this what i just described even for the small univers the x ray charge might be billed on a per d m or per item or it might be billed on by an discount and you don't know that in advance so it's only when judge table just so happens that both of you have the same care but in advance i can't tell you what talking about is what the rule wanted but the rule doesn't is silent on this but the rule assumes that because we're not looking at after the fact patient care is irrelevant but what the hospital said is that they're right negotiation is not just a volume discount but it might be billed if it's billed per d m or per item what are you supposed to put it's a legitimate question that the hospital hasn't answered now they did answer the question in the government's brief about if there's just an  just again back on the text in the meaning of standard oh and you're using the example of sticker prices on cars if you had the same statute but it was about standard car you know carse car sale prices would it be  if the government said you have to list your walk in price you have to list your preferred member price namely like aaa or something gets a discount and you have to list your corporate fleet price or lease the corporate fleet price you paid a ford would be each of those be standard prices or do you think there is no standard price in that circumstance you can't have a subset of standard prices you could have a standard price that is what the two thousand eight hundred which i mean you did address the median  average that you could have asking for the median or average i'm asking could you be required to list the price that you charge corporation ford not the standard prices anymore so they it's two answers no but at no because the statute didn't say if they had asked what is your what is your standard price for this particular location in this particular subdivision fine you still have a problem with the government says it's not an asking price it's the amount that everybody settled on so the government kind of went off a cliff because it's every price any and all and every individual negotiate o example and they were required to put on their stick on the sticker how much they charge what is their price for this car to a aaa member what is their price for this car to corporate fleet and what  yes and i was trying to say yes and so if the statute proses the question your way what is this not if it does it my way if it doesn't the what exactly the way it is in this case so this adds the word in with respect to any subpopulation so you cherry on top in fact even if everything was perfect and it was easy and no burden still would meet the statute yes so there's two layers to the argument and your point that what i hear you putting pressure on is if if you thought there was enough ambiguity that you could add some categories of patients and that's one way of looking at it i'm saying they're doing every single identified the other problem that i still think we have this argument is that if if they're right that everything specific a standard and charge is not limited emirates in specific i'm saying i'm giving you three categories in a hypothetical and a car dealership would that that as a card instead of the word hospitals a car dealer's standard charges for cars you have to do one dollar price it says cars for the way your hypo was for the walk in the arses that then you could have a standard asking price for each subset but and i under the statute or the statute have to be amended to include the word or both i think it's definitely wrong under two because then you add in they're asking for one they're asking for every next one thing to say well we'll do it by you know insurance and insured rate but if it is just your hypo is for every walk in rate that's identified are different no no no no my son my my my my question is you go to this place and your require and the rule says are those not that is that not appropriate set of standard charges were statute detention for a statute that they said what are your standard charges for cars yeah answer is now now i'm saying even if you don't like that answer it's not what the government did because the government is not the standard asking price for subsets it's the actually agreed upon price ok understood so that's all i was trying to say that i did and that