Effective 1/1/21, CMS issued CY2020 Hospital Policy Changes and Payment Rates that affect any hospital operating in the US.
About the rule
According to CMS, hospitals under the new price transparency rule – are required to post their pricing online. Pricing data must be made available for both Standard Charges– all of the hospital’s items or services, and Shoppable Services– any service that can be scheduled in advance. CMS has designated for publication 70 shoppable services. In addition, each hospital must add as many additional shoppable services required to attain at least 300, or as many shoppable services as it provides, whichever is less.
Both Standard Charges and Shoppable Services data must be updated no less than annually and clearly identify the date of update.
Standard Charges must be represented by the care setting for the hospital in a machine-readable format. These charges must include the description of the service, the gross charge, the payer specified negotiated charge, de-identified minimum negotiated charge, de-identified maximum negotiated charge, the discounted cash price, and any code used by the hospital for accounting or billing.
The information must be on a publicly available website, digitally searchable, without barriers for cost, passwords, or the use of publicly identifiable personal information.
Shoppable Services are those services that can be scheduled by a consumer in advance.
Required representations include plain language description of each service; payer specified negotiated charge by payer and plan; discounted cash price where applicable; de-identified minimum negotiated charge; de-identified maximum negotiated charge; primary code used for accounting or billing; and the location at which the shoppable service is provided.
The hospital must select an appropriate publicly available internet location to portray the data, access must be available without personal identifying information, password or payment. The information should be searchable by description [presumably plain language description does not look like this: (FGF R3 EXON7)]; billing code and payer.
Using an Internet-based price estimator tool may comply with the regulation as long as the shoppable services (for a total of at least 300) are included [Observation- for those hospitals unable to provide at least 300 hospital services, a price estimator would not meet the requirement.]; the tool allows a consumer to obtain an estimate of the amount they will be obligated to pay, the tool is prominently displayed on the hospital’s website and available without password or charge.
The rule is effective 1/1/21. Complying with the new rule is difficult as it may span multiple hospital systems to fully comply and create a burden on in-house staff that may exceed their bandwidth. However, CMS is serious about enforcement. They hosted a workshop on December 8 to promote the deadline and requirements. They have also set up a hotline for whistleblowers and can assess a penalty of about $110,000/year.
What health systems can do
- Use internal or external resources to complete an assessment of compliance. Many hospitals have previously set up online pricing estimators. These need to be reviewed for compliance.
- Develop a gap analysis and evaluate available resources by department to meet compliance needs. Evaluate the use of outside consultants and/or facilitators to promote and prioritize timely execution.
- Consider marrying other strategic initiatives as part of compliance changes enabling improvements in consumerism, revenue cycle functionality, and digital front door functionality.