CMS publishes new guidance, RFI on price transparency requirements

CMS is taking steps to comply with a recent executive order to improve and prioritize hospital price transparency requirements. On February 25, the Trump administration directed federal departments to do the following within 90 days:

• Require the disclosure of the actual prices of items and services, not estimates
• Issue updated guidance or proposed regulatory action ensuring pricing information is standardized and easily comparable across hospitals and health plans
• Issue guidance or proposed regulatory action updating enforcement policies designed to ensure compliance with the transparent reporting of complete, accurate, and meaningful data

CMS published guidance to assist organizations with encoding payer-specific standard charge dollar amounts in their machine-readable files (MRF). The agency expects that hospitals can express payer-specific negotiated charges as a dollar amount for most contracting scenarios. This value should be encoded in the corresponding MRF data element.

However, CMS recognized that there can be times when the payer-specific negotiated charge is a percentage of a fee schedule that the hospital does not have access to. In these instances, the facility should indicate that the payer-specific charge is a percentage, detail information about the fee schedule in the additional notes data element, and encode an estimated dollar amount, according to the agency.

The guidance also provides instructions for calculating the estimated allowed amount, which is the average dollar amount that a hospital has historically received from a third-party payer for an item or service. In previous guidance, CMS advised hospitals to encode 999999999 in the estimated dollar amount MRF data element when there is not sufficient reimbursement history to derive the amount. The agency determined that hospitals have been doing this more than they should, and as a result, it advised them to no longer encode this value.

When calculating the estimated allowed amount, hospitals should instead encode the average dollar amount they have received for an item or service, derived from electronic remittance advice transaction data using data from items or services rendered within the 12 months prior to posting the file, according to the guidance.

CMS also published a request for information (RFI) to get public feedback on issues affecting price transparency data accuracy and completeness. The agency is soliciting comments on MRF data quality, regulatory definitions, compliance concerns, enforcement processes, and more. The RFI comment period ends on July 21.

Editor’s note: Find more NAHRI coverage of price transparency here.