In a Final Rule released Friday, November 15th, CMS implemented the majority of its price transparency proposals but gave hospitals an extra year to comply.
By January 1st, 2021, hospitals must:
- Post standard charges for all items and services, which include:
- Gross chargemaster prices
- Payer-specific negotiated rates (which must also be labeled by plan)
- Discounted cash prices offered when patients do not use insurance benefits
- Minimum and maximum payer-negotiated rates (which do not have to be labeled by the payer)
- Separately post standard charges for 300 shoppable services
- CMS specifies 70 services
- Hospitals will pick the other 230 based on billing and visit volumes
In giving hospitals an additional year to comply, CMS appears to acknowledge that its initial estimates were too low for the burden this rule will place on hospitals. In the proposed rule, CMS estimated that each hospital would spend 12 hours and roughly $1,017 complying annually. In the Final Rule, CMS states that compliance in 2021 will cost each hospital about 150 hours and roughly $11,898. Those revised estimates are each about 12 times higher than the prediction in the proposed rule. In 2022 and subsequent years, CMS estimates compliance will cost each hospital about 46 hours and roughly $3,611.
The Final Rule also clarifies what criteria an online, self-service estimator must meet to comply with the requirements of the shoppable service:
- Provide estimates for at least 300 shoppable services, including as many of the 70 required by CMS that the hospital provides
- Generate an estimate for the patient in real-time
- Be prominently advertised on the hospital’s website
- Be free to use
- Does not require the patient to register to use it (such as by creating a user name and password)
Therefore, it appears that estimators housed within patient portals, such as Epic’s MyChart, do not meet the criteria.
Healthcare Business Insights members can click here to access a full summary of the Final Rule, including compliance checklists and information about civil monetary penalties and the appeal process. Nonmembers who would like a copy can request one by filling out the form below.
In tandem with these requirements, CMS released a proposed rule that would impose price transparency requirements on health insurers.
Among other provisions, the Transparency in Coverage proposed rule (full text available here) would require health insurers to:
- Provide their beneficiaries with personalized cost estimates for covered services, both online and in a paper format
- Publish their negotiated in-network rates with contracted providers
- Publish allowed amounts they have historically paid to out-of-network providers
Comments on the proposed rule are due within 60 days once the rule is officially released in the Federal Register.
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