After a series of Price Transparency audits, CMS is proposing additional modification under the CY 2024 OPPS proposed rule. If finalized, the rule would require that providers post standard charges data using CMS templates, which are available for voluntary use now. The rule would be effective January 1, 2024, with an enforcement grace period for adoption of the CMS template and encoding additional data elements until March 1, 2024.

CMS initially finalized Price Transparency requirements in 2019 and required provider compliance by January 2021 . The rule lists a set of required data elements that would need to be encoded in standard charge information:

  • General data elements including hospital name, license number, location name(s), and address(es) at which the public may obtain the items and services at the standard charge amount indicated in the Machine Readable Files (MRF); the version number of the file and the date of the most recent update of the standard charge information in the file.
  • Each type of standard charge (defined at 45 CFR 180.20). For payer-specific negotiated charges, the hospital must include: the payer and plan name (as specified in the contract); the type of contracting method used to establish the standard charge; whether the standard charge indicated should be interpreted by the user as a dollar amount, or if the standard charge is based on a percentage or algorithm, and what percentage or algorithm determines the dollar amount for the item or service. If the standard charge for an item or service is expressed as a percentage or algorithm, the hospital would be required to indicate a consumer-friendly expected allowed amount in dollars for the item or service.
  • A description of the item or service that corresponds to the standard charge established by the hospital, including a general description; whether the item or service is provided in connection with an inpatient admission or an outpatient department visit; and for drugs, the drug unit and type of measurement.
  • Any codes used by the hospital for purposes of accounting or billing for the item or service, including modifier(s) and code type(s).

Under these new requirements, hospital MRFs would need to include and attestation indicating that the hospital, “to the best of its knowledge and belief, has included all applicable standard charge information in accordance with the requirements of 45 CFR part 180 and that the information displayed is true, accurate, and complete as of the date indicated in the file.”

In addition, CMS is also proposing changes to the MRF files itself. First, hospitals would need to place a ‘footer’ at the bottom of the hospital’s homepage that links to the webpage that includes the MRF. Second, hospitals would need to ensure that a .txt file is included in the root folder of the publicly available website chosen by the hospital for posting its MRF.

Additionally, CMS would update enforcement provisions in 45 CFR 180.70. If finalized, the rule may require submission of certification by an authorized hospital official as to the accuracy and completeness of the data in the machine-readable file. Hospitals may also be required to submit acknowledgement of receipt of any warning notices issued by CMS to the hospital. The rule would also authorize CMS to notify and work with health system leadership to correct deficiencies found in one hospital’s MRF and standard charge information across all hospitals in the system. CMS would also be able to publicize information related to assessment, compliance, and enforcement of these rules.

In addition to proposing these new Price Transparency rules, CMS is also requesting comments on how to further develop consumer-facing pricing information on both the Price Transparency Rule and the disclosures under the No Surprises Act. Comments are due to CMS by September 11, 2023.

For any questions regarding proposed updates to the Price Transparency rule, impact on providers, or any other health care regulatory and/or operational matters, please contact Advis or call 708.478.7030.

Published: July 25, 2023