Final check: Last minute tips for price transparency

Wednesday, November 4, 2020

The deadline to comply with CMS’ expanded price transparency requirements is almost here. When the new year starts, hospitals must be in compliance with the Hospital Price Transparency final rule. When the final rule was published late in 2019, most revenue integrity professionals were relieved that the effective date of January 1, 2021, allowed a full year to prepare. But this hasn’t been an ordinary year and complying with expanded price transparency requirements may have taken a backseat to other urgent considerations.

With the clock running out and the novel coronavirus (COVID-19) pandemic still ongoing, can hospitals expect any relief? Don’t count on it, NAHRI Advisory Board member Valerie A. Rinkle, MPA, CHRI, lead regulatory specialist and instructor for HCPro, said during the day one session “CMS’ Major Policies for CY 2021 IPPS, OPPS, and MPFS – Part 2” at Revenue Integrity and Reimbursement Strategies: A NAHRI Virtual Event, held October 6–8.

“I don’t think CMS is going to delay implementation,” she said. “I think this is a key topic that they want to get leverage on, so they want hospitals to publicize their chargemaster information.”

So what requirements will go into effect next year? The Hospital Price Transparency final rule builds on earlier requirements in the 2019 IPPS final rule. Hospitals will be required to post their standard charges for all items and services in a machine-readable file. Notably, the final rule adopted a more specific definition of standard charge that is broken down into four types of charges:

  1. De-identified minimum and maximum negotiated charges
  2. Discounted cash prices
  3. Gross charges
  4. Payer-specific negotiated charges

 

It’s critical to look closely at how CMS defines standard charges and the type of information that will need to be publicized for each type of charge, Rinkle said. The payer-specific negotiated charges may be a particularly difficult requirement to fulfill. Hospitals may treat patients with hundreds of different health plans. Posting this information in a format that’s useful and fulfills CMS’ requirements could be challenging.

“Are you also going to then literally list the major payers and post the payer specific rates?” Rinkle said. “I do think [it was clarified] that it would be the major contracts. If 10 different plans are under the same contract, you can just name it once. You don’t have to have to list the 10 individual payers.”

Hospitals will also be required to post a separate list of 300 shoppable services. According to the final rule, a shoppable service is a service that can be scheduled in advance and may be elective. The list is broken down into 70 CMS-selected services specified in the final rule, with the rest of the list comprised of 230 services selected by the hospital. But what if a hospital doesn’t offer 230 shoppable services?

Hospitals that don’t offer an additional 230 shoppable services will instead post as many as they offer, Rinkle said. Those hospitals’ lists of shoppable services would therefore be shorter than 300.

CMS is offering an alternative to the requirement to post a list of 300 shoppable services, Rinkle noted. Hospitals may fulfill this requirement by providing a patient-facing price estimator tool. Although some hospitals may have the resources to develop the tool internally, many may opt to work with a vendor.

CMS recently launched a hospital price transparency website for providers and patients. The website includes links to price transparency rules, information for providers and patients, and a resource section with an FAQ.

On October 29, CMS released the Transparency in Coverage final rule. This rule is aimed at payers and will require them to publish a list of 500 shoppable services by 2023 with additional requirements set to roll out in 2024. Although changes may occur before those requirements go into effect, hospitals should consider this a signal that CMS doesn’t intend to budge on publishing payer-specific negotiated rates.

Editor’s note

Revenue Integrity and Reimbursement Strategies: A NAHRI Virtual Event includes 12 educational sessions covering CMS’ final and proposed payment system rules, chargemaster management, revenue integrity process improvement, external audits, billing and coding updates, and more. Click here to learn more about how to access the on-demand version and to see the full agenda and learn about exclusive NAHRI member discounts and group rates.

More Like This

Get Your Coding Right the First Time—Prior to Billing—with Automated Analysis from eValuator