CMS Proposes Broad Changes to the Hospital Price Transparency Initiative For 2020

Articles

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on July 29 that includes several sweeping changes to the Hospital Price Transparency Initiative that has been in effect since January 1, 2019. Immediately following is a description of the proposed changes – it's lengthy, and necessarily, somewhat detailed, but we want to let you know that your call to action comes after the description we provide of the proposed changes. CMS is asking for input on these proposals from interested stakeholders. If you count yourself an interested stakeholder (and we hope you do) please use the contact information we provide at the close of this article and let your voice be heard.

Specifics of The New Transparency Proposal

The proposed addition to title 45 of the Code of Federal Regulations (CFR), if approved, would enact the following new requirements:

  • Define a hospital to include any institution licensed as a hospital by the state or other applicable locality, regardless of whether or not the institution is enrolled in Medicare. This proposed definition would include critical access hospitals (CAHs), inpatient psychiatric facilities (IPFs), sole community hospitals (SCHs), and inpatient rehabilitation facilities (IRFs) operating in all 50 states, Washington DC, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
  • Provide an exemption to the requirements for federally-owned or operated hospitals, for Indian Health Services (IHS), Veterans Affairs (VA) hospitals, and Military Treatment Facilities (MTFs).
  • Define “Items and Services” to include all items and services provided by the hospital including individual items/services and service packages a patient receives in connection with an inpatient admission, or outpatient department visit, for which a standard charge has been established. This would include charges per DRG (diagnostic related grouping), where applicable.
  • Require that hospitals post “standard charges” for all items and services as defined above. “Standard charges” would include gross charges in addition to payer-specific negotiated charges. (This definition will include all charges that the hospital has negotiated with third-party payers for an item or service.) Note that this definition will include posting of negotiated charges with Medicare Advantage plans, but it won't include charges negotiated with individual self-pay patients.
  • Require that hospitals publish their “standard charges” publicly in two ways: 1) A machine-readable file of standard charge information for all hospital items and services, example formats include: .XML, JSON or .CSV; and 2) A consumer-friendly display of common “shoppable services" derived from the comprehensive file.

    Note that “shoppable services" will include services that can be scheduled by healthcare consumers in advance, and the definition will also include services that are routinely provided in non-urgent situations.

    CMS has published a listing of 70 “shoppable” services, including:
    • Evaluation & Management (E/M) services, including psychotherapy sessions, consultations, and routine office visits;
    • Routine laboratory tests;
    • Radiology services, including but not limited to routine x-rays, CT scans, MRIs, ultrasound exams, and mammography;
    • Routine surgical services, including spinal fusions, tonsillectomy, colonoscopy, gallbladder removal, vaginal and Cesarean delivery services, EKG, and sleep studies— among many others;
  • The proposed rule further requires that these files be posted to an Internet location that is publicly available, prominently displayed with the hospital’s location clearly identified, digitally searchable, and available without restrictions such as password requirements or submission of patient information before accessing the data.
  • It also requires the following data elements for all hospital items and services:
    • A description of each item or service
    • The corresponding gross charge for each item or service
    • The corresponding payer-specific negotiated charge for each item or service
    • Any code used for purposes of accounting or billing for the item or service, including but not limited to Current Procedural Terminology (CPT®) code, HCPCS code, DRG, National Drug Code (NDC), revenue code, or other common payer identifiers.
  • Finally, it specifies that this information must be updated at least annually, although more frequent updates will be encouraged.

Enforcement Proposals

CMS plans to monitor each hospital’s compliance with these new regulations based on their analysis of noncompliance, and through consumer complaints made to CMS. They are also proposing a monetary penalty for noncompliance, following a written warning and request for a corrective-action plan from the hospital. The current proposal includes a $300 per-day penalty that could be assessed if a hospital is deemed to be noncompliant with these regulations.

Now It's Your Turn: CMS Wants Your Input

It is important to remember that all of these regulations are still proposals, and that's why it's critically important for interested stakeholders to make their voices heard. CMS will be accepting public comments on these proposals until 5:00 p.m. EDT on September 27, 2019. Comments may be sent in one of several ways:

Submit electronically at www.regulations.gov

Submit via regular mail at:

Department of Health and Human Services
Attention: CMS-1717-P
P.O. Box 8013
Baltimore, MD 21244-1850

Submit via express or overnight at:

Department of Health and Human Services
Attention: CMS-1717-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850

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