Experts weigh in on implications of price transparency, proposed E/M documentation and reimbursement changes

Wednesday, October 17, 2018

CMS’ latest payment system changes and the implications for 2019 and beyond made waves on day one of the 2018 Revenue Integrity Symposium in Litchfield Park, Arizona. Attendees at the back-to-back general sessions on October 16 had the opportunity to ask revenue integrity experts questions about the 2019 outpatient prospective payment system (OPPS) and Medicare physician fee schedule (MPFS) proposed rules and revenue integrity hot topics, including price transparency, Medicare Advantage contracting, noncovered services, and more.

Board members offer tips, analysis in panel discussion

NAHRI board members Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, Elizabeth Lamkin, MHA, John Settlemyer, MBA, MHA, CPC, and Angela Lynne Simmons, CPA, kicked off the first general session by digging into some of the major current revenue integrity challenges. The panel discussion touched on hot button issues such as price transparency and the implications of CMS’ 2019 inpatient prospective payment system (IPPS) final rule requirement that hospitals post their chargemaster online.

CMS’ focus on price transparency is aimed at helping patients understand the cost of care and be able to prepare for any costs for which they may be responsible. However, the panelists agreed that because the charges listed in the chargemaster do not translate directly into the costs patients may see it’s unlikely this requirement will truly meet CMS’ stated goals. “From the patient standpoint we know this is not helpful,” Settlemyer said. “We want to encourage you to think of further steps that could guide patients to greater clarity.”

Some states already have price transparency regulations, including requiring hospitals to post their chargemaster online, Simmons noted. However, each state has different requirements and different methods. Therefore, CMS appears to have decided that it was its duty to step in and institute a uniform national policy, she said. Simmons recommended that to prepare to post their chargesmaters online, hospitals take the following steps:

  • Review existing state requirements regarding hospital pricing and price transparency
  • Review chargemaster for consistent pricing
  • Communicate the new requirements to all stakeholders, including IT as this department will be instrumental in meeting the technical requirements of posting the chargemaster online
  • Choose a date to post the chargemaster; this will be done annually, so ensure that it leaves enough time to gather and send the information to IT
  • Write customer service scripts to address patients’ questions about the chargemaster and pricing

Ensure staff involved in clinical research are informed of the new requirement and the potential implications for research sponsors, she added. “We see a fair amount of risk in this project,” she said.

There is also a potential for risk if proprietary Common Procedural Terminology (CPT®) or revenue code information is included in the chargemaster and posted online, Settlemyer said. Check with compliance and legal staff to determine if your organization is at risk and how to handle this circumstance.

The far-reaching implications of CMS’ price transparency requirements were apparent during the panel’s discussion of observation services. These services are notoriously tricky for hospitals and a common source of denials. Another layer of complexity will be added when hospitals must determine how to list charges for observations service in the chargemaster after January 1, 2019. The charge for these services is dependent upon location, Goodman pointed out, so patients will not be able to look up one standard charge for observation. “When you have to post your chargemaster you’re going to have to make some decisions about how you’re going to report the charge description code and price,” she said.

Lamkin lead a discussion of the challenges surrounded Medicare Advantage (MA) contracting. Hospitals must keep in mind that MA plans are not Medicare – although they must follow Medicare’s policy manual they are private insurance plans with specific contract terms. It’s critical that utilization review (UR) staff and case managers are cognizant of MA contract terms but too often hospital contract staff do not share this information, Lamkin said. She recommended that hospital contracting staff work with UR staff, including physician advisors, to understand how contract terms translate in the clinical setting. Contracting staff should use this feedback to propose changes during contract renewal negotiations, she added.

The panel wrapped up with a discussion of strategies to address billing for noncovered services. No shows are among the most common noncovered services. Unlike some noncovered services, which may not be billable to patients, hospitals don’t need to write off missed appointments. “Commercial payers don’t consider it a covered service, but they will allow you to bill the patient,” Settlemyer said.

Ensure that patients understand their financial obligation if they miss an appointment without giving reasonable notice, he added. Hospitals can post information in lobbies and waiting areas.


Jugna Shah, MPH, put the 2019 OPPS and MPFS proposed rules under the microscope in the second general session. Key themes across both rules include efforts to reduce physicians’ paperwork and expand site neutral payment policies, she said. Both rules also include complex and potentially interrelated proposals.

“I think the 2019 proposed rule has the most changes to the MPFS in 20 years,” Shah said. “Massive disruption will occur if any number of these proposals are finalized.”

Two of the most talked-about proposals in the MPFS are the proposal to allow physicians to choose which evaluation and management (E/M) documentation standard they will use and the proposal to collapse E/M levels 2 through 5 into one payment category. Hospital-based staff usually might not pay attention to the MPFS, they would be impacted by the proposed E/M changes, Shah said. And while physicians might welcome the proposed changes to E/M documentation, it’s unlikely that CMS will finalize that without also finalizing the proposed E/M changes. Due the complexity of the proposed changes and the amount of regulatory guidance CMS would need to issue by January 1, 2019, Shah said it’s unlikely that either will be finalized. However, if the agency does not finalize these proposals for 2019 it will likely offer similar proposals for 2020.