As part of the Calendar Year 2024 Outpatient Prospective Payment System and Ambulatory Surgical Center Proposed Rule issued on July 13, 2023, the Centers for Medicare and Medicaid Services (CMS) proposed changes to the hospital price transparency regulations. The proposals are part of CMS’ efforts to increase hospital compliance with the regulations as well as to streamline and clarify certain components of the regulations. CMS is seeking comment on the following proposals through Sept. 11, 2023:

CMS reiterated the existing requirement for hospitals to display a list of their standard charges for items and services provided to patients in a comprehensive, machine-readable format. Standard charges include gross charges, discounted cash price, payer-specific negotiated charge, and de-identified minimum and maximum negotiated charges. CMS is suggesting changes to the standard charge display requirements at 45 CFR §180.50, as well as the enforcement provisions at 45 CFR §180.70 to improve the enforcement process.

Changes to Machine Readable File

CMS is looking to require hospitals to display the required standard charges data using a CMS template including a data dictionary and affirm that to the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the regulatory requirements, and that the information displayed is true, accurate, and complete as of the file date. CMS is proposing that, although these requirements would become effective on January 1, 2024, CMS would not begin enforcement efforts until March 1, 2024. The CMS templates would be provided in three formats, i.e., a CSV “wide” format, a CSV “tall” format, and a JSON schema, which would resemble the samples that are currently available on the CMS hospital price transparency website.

In addition to the templates, CMS wants hospitals to adhere to a set of required data elements as follows:

• Hospital name, license number, location name(s), and address(es) at which the public may obtain the items and services at the standard charge amount indicated in the MRF; the version number of the file and the date of the most recent update of the standard charge information in the file.
• For payer-specific negotiated charges: the payer and plan name, type of contract, including whether the charges are dollar amounts, percentages, or algorithms, and what percentage or algorithm determines the dollar amount for the item or service. If not in a dollar amount, the hospital would need to provide a consumer-friendly expected allowed amount in dollars for the item or service.
• A description of the item or service for each standard charge that includes a general description and whether the item or service is provided in connection with an inpatient admission or an outpatient department visit. For drugs, the hospital would need to provide the drug unit and type of measurement.
• Codes, including modifiers, used for billing/accounting for the item or service.

CMS also proposes to require the placement of a footer at the bottom of the hospital’s homepage that links to the webpage that includes the machine-readable file and requiring hospitals to ensure that a .txt file is included in the root folder of the publicly available website for the purpose of identifying the URL for both the file and the webpage that contains the link to the file.

Enforcement Efforts

CMS also proposes updates to the enforcement provisions to add items, such as:

• Requiring the submission of certification by an authorized hospital official as to the accuracy and completeness of the data in the machine-readable file.
• Requiring hospitals to submit an acknowledgement of receipt of the warning notice in the form and manner and by the deadline specified in the CMS notice of violation.
• Notifying health system leadership of any action taken against one of its hospitals and working with them to address similar deficiencies for the system’s other hospitals.
• Publicizing information related to a hospital’s compliance, and action taken by CMS, the status of such action, and health system leadership notifications.

Transparency in Coverage (TIC) and No Surprises Act (NSA) Alignment

The price transparency regulations require hospitals to display some of their standard charges in a consumer-friendly manner for 300 shoppable services and deem hospitals to be in compliance if the hospital elects to offer an online price estimator tool. CMS noted that the TIC and NSA rules have allowed a more complete release of consumer-friendly pricing information and consumer protections (i.e., a dispute process), if the final bill is significantly different from the estimate. CMS is interested in comments regarding possible future modifications to the transparency regulations in light of these protections.

We continue to assist hospitals with price transparency efforts and responses to CMS inquiries. Should you have any questions regarding this summary or compliance with the existing regulatory requirements, please contact one of the authors.