Navigating New CMS Guidelines: Ensuring Hospital Price Transparency Compliance


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April 29, 2024

Author: David Mistkawi, VP of Access Mgmt. Solutions at The SSI Group, LLC

Staying abreast of this year’s transparency compliance regulatory changes is paramount for hospitals and health systems to maintain financial integrity and foster patient trust. To ensure avoiding the CMS Enforcement Actions, it’s crucial to understand the latest requirements and new guidelines set forth by the Centers for Medicare & Medicaid Services (CMS), effective as of January 1, 2024. In 2023 the range of penalties levied for price transparency violations was from $56K – 970K, and spanned large and small organizations alike, showing that there is still work to be done to bring all hospitals and health systems into compliance. However, for many facilities, the reality of the first quarter clearinghouse drama has pushed what should have been a 2024 priority to the bottom of the to-do list.

Requirement Updates for Hospital Pricing Transparency
Since 2021, hospitals have been mandated to disclose certain price and payer data to the public, aiming for increased transparency in healthcare pricing. As a quick review of what hospitals must make public to be compliant with 45 CFR §180.40, here are the standard charges that must be disclosed for items and services provided to a specific group of paying patients:

  1. The gross charge (the charge for an individual item or service that is reflected on a hospital’s chargemaster, absent any discounts).
  2. The discounted cash price (the charge that applies to an individual who pays cash, or cash equivalent, for a hospital item or service).
  3. The payer-specific negotiated charge (the charge that a hospital has negotiated with a third-party payer for an item or service).
  4. The de-identified minimum negotiated charge (the lowest charge that a hospital has negotiated with all third-party payers for an item or service).
  5. The de-identified maximum negotiated charge (the highest charge that a hospital has negotiated with all third-party payers for an item or service).

In 2024, CMS has increased the burden on hospitals and health systems by adding further requirements of uniformity and accessibility across the industry. Here’s how RCM leaders can ensure compliance and meet CMS standards:

Adopt the New CMS Templates for Increased Consumer Access and Readability
CMS has introduced a standardized template for displaying price and payer data, ensuring consistency and ease of understanding for consumers. The Hospital Price Transparency machine-readable file (MRF) is a single digital file intended to be read by machines able to process hospital standard charge information. By using the MRF, hospitals ensure they display their standard charge information using a CMS template layout, data specifications, and data dictionary. The CMS templates are offered in a comma-separated values (CSV) “wide” format, a CSV “tall” format, and a JSON schema. Hospitals will be required to encode standard charge information in the CMS templates as well as conform with other specified technical instructions that are the data dictionary. By implementing the CMS-approved format, hospitals streamline the process of displaying pricing information and facilitate consumer comprehension, as well as being compliant.

Include the Required Affirmation Statement on Your Website
In addition to displaying price data, hospitals are now required to include an affirmation statement on their website and in their MRF. The hospital must profess that to the best of its knowledge and belief, it has included all applicable standard charge information in accordance with the requirements of 45 CFR part 180 and that the information displayed is true, accurate, and complete as of the date indicated in the file. This statement confirms the accuracy and completeness of the disclosed information, instilling confidence in consumers regarding the reliability of the provided data. Revenue cycle leaders should ensure that the affirmation statement is prominently featured on their websites, reinforcing their commitment to transparency and accountability.

Make Information Easy to Find for Both Patients and Oversight Agencies
To ensure that consumers can readily access and comprehend price transparency data, hospital websites should feature intuitive navigation and prominently display links to the price transparency section. Specifically, CMS regulations favor automated access and real-time centralization of the files and standard charges data, and:

  1. require hospitals to place a ‘footer’ at the bottom of the hospital’s homepage that links to the webpage that includes the MRF; and
  2. require hospitals to ensure that a .txt file is included in the root folder of the publicly available website chosen by the hospital for posting its MRF. The .txt file must identify the URL for both the MRF and the webpage that contains the link to the MRF.

CMS believes these requirements will improve the automated accessibility of hospital standard charges information and streamline CMS enforcement of the requirements. By making information easy to find, revenue cycle leaders not only ensure compliance with the 2024 CMS regulation updates but also enhance the consumer experience and foster trust in their institution’s commitment to transparency.

Consider SSI Estimation – An Automated Price Transparency Solution
For hospitals seeking streamlined compliance with price transparency requirements, automated solutions offer a compelling option. Market-tested tools, such as SSI Estimation, can deliver real-time answers and simplify the process of data disclosure while ensuring accuracy and consistency. SSI Estimation includes both a provider and a patient-specific component to ensure the price transparency needs of each are met. The online patient estimation feature empowers consumers with the ability to obtain accurate, reliable estimates for common procedures via your website with just a few clicks on a computer or mobile device. Estimates created online by patients are then saved in the system, allowing front-line staff to review for appropriate follow-up and scheduling.

The provider-specific side of the solution enables health systems to strengthen compliance and consumer satisfaction simultaneously. By modeling estimation to match providers’ payer contracts, integrating charge history, and leveraging the benefits information in the eligibility response, SSI is able to produce the most accurate estimate possible for users. An added bonus to the product’s features is enhanced patient communication. With custom scripting and dynamic estimate letters, what were once uncomfortable financial discussions can become opportunities to collect from patients by presenting information in a clear, concise, and consumer-centric manner. Select an automated solution that has been proven to be simple, accurate, and reliable. By leveraging SSI Estimation, hospitals can not only fulfill regulatory obligations but also cultivate stronger patient loyalty and optimize cash flow.

In conclusion, navigating the evolving landscape of hospital price transparency requirements demands proactive measures and strategic initiatives from revenue cycle leaders. By adopting the new CMS template, including an affirmation statement, prioritizing accessibility, and leveraging automated solutions, such as SSI Estimation, you can not only comply with regulatory mandates but also enhance the consumer experience and reinforce trust in their commitment to transparency. To discuss all of the solutions bundled into SSI Access Director, or just SSI Estimation specifically, request a demo or call 800-881-2739.

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