Hospital Price Transparency: What Hospitals Need to Know
Date:
Duration: approximately
minutes
Featured Speaker
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Carmen Irwin, Health Insurance Specialist, Centers for Medicare and Medicaid Service |
Beginning January 1, 2021, hospitals operating in the United States are required to provide clear, accessible pricing information online about the items and services they provide. This webinar will discuss the latest hospital price transparency policies effective January 1, 2024. The Centers for Medicare and Medicaid Services (CMS) subject matter experts will review the latest policy requirements and enforcement actions for hospital price transparency.
Additional Resources
From This Webinar
Transcript
Kristine Sande: I'm Kristine Sande and I'm the program director of the Rural Health Information Hub and I'd like to welcome you to today's webinar where we'll be discussing Hospital Price Transparency: What Hospitals Need to Know. We have provided a PDF copy of the presentation on the RHIhub website and that's accessible through the URL on your screen. And so, now it is my pleasure to introduce our speaker for today.
Carmen Irwin, health insurance specialist, has been with the Centers for Medicare and Medicaid Services, Dallas Regional Office since 2002. She currently serves as the Office of Program Operations and Local Engagement Hospital Price Transparency team member. Carmen has worked with several Medicare contractors for both program integrity and Medicare policy. Carmen has also served as the lead for provider relations, DMEPOS policy lead, Medicare Part A and B policy areas and rural health coordinator for the CMS Dallas Regional office. Carmen holds a Bachelor of Science in Political Science and History from Francis Marion University in Florence, South Carolina. And with that, I'll turn it over to you, Carmen.
Carmen Irwin: What a joy and pleasure to be here today with you all. We're very excited to provide information with regards to HPT. Again, my name is Carmen Irwin, I'm with CMS, I am a team member for the HPT compliance team. Today we are going to go over a few of the highlights for HPT, Hospital Price Transparency, and basically go over some of the newer requirements that came into play as of January 1st of 2024.
Now, with this presentation, as always, the information I'm presenting today is just a reference for you but not a legal document. As I'm sure you're aware, information presented by CMS in different webinars can change over time or become out of date, however, all this information is accessible through the PowerPoint provided and then, of course, the URLs are links to the CMS website which has a specific HPT landing page.
So, as we get started, we're going to talk a little bit about how this came about, how the regulation for HPT, just presenting some of the information here today. So, discussing the new requirements as part of the Hospital Price Transparency Initiative. The legal authority for the hospital price transparency comes from section 2718 of the Public Health Service Act. And in this act, the law requires each hospital operating within the United States to annually establish and make public a list of hospital charges, or standard charges rather, for items and services that it provides and requires the secretary to tell hospitals how to make these standard charges public.
The law was delegated to CMS to implement so CMS promulgated new regulation at 45 CFR 180 that became effective January 1st, 2021. Now, through rulemaking, we explained our belief that public release of hospital standard charge information is necessary and an important first step for bringing transparency to healthcare pricing and that the regulations are designed to begin to address some of the barriers that limit price transparency with the goal of increasing competition among healthcare providers for bringing down cost. The hospital price transparency regulation requires to make public standard charges.
The hospital has to do this in two ways. As you can see here, the first is a comprehensive machine-readable file with the standard charges for all the items and services, we will refer to this later on in the presentation as an MRF. Also, as a display of consumer-friendly standard charges or 300 shoppable services.
So, today in our presentation, we're going to focus a little bit on the first two main requirements that are required for the hospitals to make public.
In our changes or in the regulatory updates that I mentioned above and the calendar year 2024 OPPS ASC Final Rule, some of those changes that were agreed upon or came into regulation are listed here. Now, as you'll see, there is a timeline associated with those.
Now, the first one, which was on January 1st of this year, 2024, there were two requirements that were put into place for hospitals. Those requirements included a TXT file in the footer, I'm sorry, in the root folder of the machine-readable file and contact information, which you can see is in regulation 45 CFR 180.5, and then hospitals must place a footer at the bottom of the hospital's home page that links to the web page that includes their machine-readable file and, again, based on 45 CFR 180.5. Now, going through this timeline, you'll see that, as of July 1st of 2024, there are additional requirements, and we'll go over those, for new data elements and format standardization that's going to be required.
So, this will include hospital's MRFs must conform to the CMS template layouts and data specifications. It did expand this set of data elements including each type of standard charge, payer specific negotiated charges by payer and plan, and item in service descriptions and relevant billing codes. In addition to that, January 1st of 2025, there will be additional required data elements that will be required in that machine-readable file and those include drug unit of measure, drug type of measurement, and some modifiers.
So, let's talk about how improving automated access to our MRFs. That first, of course, is the requirement for January 1st, 2024 where hospitals must ensure that the public website it selects to host its machine-readable file, or MRF, establish and maintains in the format that manners specified by CMS. So, what does that mean? So, that means a TXT file in the root folder of the hospital's website. That TXT file must contain the hospital location name that corresponds with the machine-readable file, the source page for the URL that host the machine-readable file, a direct link to the MRF or the MRF URL and then the hospital point of contact information. In addition, a link in the footer on its website, including but not limited to the home page, that is labeled price transparency and that links directly to the publicly available web page that hosts the machine review file for the hospital.
Now, CMS has put out instructions and there's also a generator tool on our website for your TXT file, it's called a TXT file generator. Towards the end of the presentation, I am going to reference and show you where all those tools are located and the website or the URL for that tools website that you can access all the HPT tools. But again, these two requirements began January 1st of 2024.
So, let's talk a little bit about the next requirements that go into effect for July of 2024 and that's going to be the CMS template and technical requirements. So, as of July 1st, hospital's MRF must conform to CMS template layout, data specifications, and the data dictionary. CMS has made available the templates and they're available in three non-proprietary formats. That would be the CSV “tall”, the CSV ”wide”, and the JSON. Now, CMS has created a GitHub repository to house the required CMS templates and provides the data dictionary and technical instruction on how hospitals must encode their standard charge information onto the machine-readable files. Again, we will reference that tools page when we get to the end of the presentation.
Here you have the link, this is where the data dictionary GitHub repository is available, this is where the three formats are found, the CSV “tall”, the CSV “wide”, and the JSON. In addition, this is where you can submit questions or follow the chat where we have available, where people have submitted already some questions or maybe some technical information with regards to those three different templates that are available.
So, let's talk a little bit about the data elements. We said that, with the requirement coming in July 1st for the three different templates, there are specified data elements that go with them. So, those data elements are pretty much specific to standard charge, item and service information, and coding information. This information, of course, will help you contextualize the standard charge your hospital has established. In addition, this information is available and listed for each one of the templates on that GitHub repository where we have the data dictionary that coordinates with every template whether it be the CSV “wide”, the CSV “tall”, or the JSON.
The data element overview is listed here also. Hospitals must adopt a CMS template layout and encode the data elements according to the technical specification described in the data dictionary. Again, just to reiterate, that data dictionary, you can find it on the repository on the GitHub website. The data elements are organized in these five groups. That first group, as you see here on the slide, is your MRF information, the date, CMS template version, and the affirmation statement. Then that second section of course is hospital information, pretty self-explanatory. Then you have the layout of the standard charges. Then you have the information on the item in service information. And, then the last is the course coding information. And again, all are available on that GitHub website when you look at the data dictionary that goes with the template.
Now, there are three ways in which to display payer-specific standard charges and, as you see here, we've broken them out. Again, repetitive, I know, but this information is provided in that data dictionary. So, you have the dollar amount, so that's the payer-specific negotiated charge expressed in a dollar amount that a hospital has negotiated with a third-party payer for the corresponding item or service. Then you have the payer-specific negotiated charge which is expressed as a percentage that a hospital has negotiated with a third-party payer, this data element will contain the numeric representation of the percentage, not as a decimal and we've given you a little example there.
And then of course the third, which would be the algorithm, payer-specific negotiated charge expressed as an algorithm that a hospital has negotiated with a third-party payer for the corresponding item or service. And we've underlined it here, but display a payer-specific negotiated charge as a dollar amount whenever possible. And again, this is expressed and detailed in that data dictionary on the GitHub website that goes over those three formats, whether it be the CSV “tall”, the CSV “wide”, or the JSON.
So, payer-specific negotiated charge contextual information. So this information is for each payer-specific standard charge your hospital has established and you must encode a standard charge methodology. That could be the case rate or a flat rate for a package of items or services triggered by a diagnosis, treatment or condition for a designated length of time. You have the payer-specific negotiated charge fee schedule amount, the percentage of total bill charge, you also have the per diem or per day rate charge, and then there's also other. And, if the standard charge methodology used to establish a payer-specific negotiated charge cannot be described by one of the four previous. Again, just to repeat, this information is in the data dictionary which you will find on the GitHub website.
Now, CMS did account for additional, optional rather, data elements. They are not in regulation at this time, however, they are not required but you can add them to support the standardization of the disclosure of these data elements in your file and that would be the hospital financial aid policy and then, of course, the billing class that can be added to the file if the hospital chooses to do so, they are not required at this time. And again, this is explained in the data dictionary on the GitHub website.
So, we did an introduction to the CMS templates and data dictionary, here is the link that would direct you to that data dictionary GitHub repository. Again, we will provide you with all this information at the end on the tools page but this is the direct URL that will send you to that data dictionary on the GitHub website for HPT for those of you that are looking to see those templates.
Again, the CMS GitHub repository is the website used by CMS to store the templates and the data dictionary with all the technical instructions that your hospital must use to create its machine-readable file. It does provide assistance for technical questions, and it also makes available voluntary tools that would be, as we discussed previously, a TXT generator for that TXT requirement and to help your hospital comply with the price transparency regulatory requirements. All this is housed at that site.
So, accessing technical instructions and examples. This also, of course, is housed at the data dictionary GitHub repository. The one thing I would like to point out is, when you go to that GitHub website, there are a few README documents that I would urge you to read first. When you're looking at those templates and at the data dictionary, we do have some README documents that help follow or help provide a path to how the hospital can do the work in putting those templates together or accessing information for technical direction when putting your information in those templates.
Again, reiterating our hospital price transparency resources, the data dictionary GitHub repository and then, of course, our HPT website resource page. That resource page is a landing page, it does break it out in hospitals and providers, you can go to the hospital link and it will provide you the same information. It will provide you directions to our FAQs, how to create a shoppable services file, and some other technical direction that is available with regards to our HPT setup or questions that you may have.
We're going to switch gears here. We've gone over the nuts and bolts of what's required by a hospital, the updates for January 1, which is the TXT and footer requirement. We've discussed a little bit about that is coming for July 1st, which is the mandatory use of the templates, the CSV or JSON. Now let's talk a little bit about what we do with our compliance overview.
So, the assessment or compliance assessment is the work that's being done with the review of the actual file or MRF. So, during a comprehensive review, CMS assesses whether the hospital's disclosure of standard charges meets the requirement that is specified in the 45 CFR. Specifically, CMS assesses whether the hospital has displayed appropriately the standard charges in the machine-readable file in accordance with the criteria established and the shoppable services in a consumer-friendly manner which is also in accordance with the criteria that was established. The machine-readable file and shoppable services file or a price estimator tool are evaluated based on compliance with regulatory requirements including the contents of the file, the file's accessibility, and the date of the last update. Once that file is reviewed and after the initial review, CMS determines whether or not the hospital file is in compliance with the final rule.
So, at that time, the following actions typically occur. So, CMS issues what we call a warning notice indicating the violations, if there are, in that machine-readable file that the hospital has posted. That warning notice must be acknowledged by the hospital within five days of receipt. Our warning notices are sent to the hospital via FedEx and so what we're looking for is, when the hospital does receive that initial notification, that they respond as stated in the notice to an email box acknowledging receipt of that warning notice. If CMS determines that the hospital resolved the violations within 90 days after receiving that warning notice, CMS then issues what we call a closure notice. So, if after 90 days, we test it or review it again and the file is complete, that hospital will receive a closure notice.
Now, if after 90 days, CMS determines that the hospital has not resolved those violations, the hospital will receive a corrective action plan request letter or a CAP letter. Now, we do have something highlighted here, though the compliance process typically begins with a warning notice, if, for some reason, the hospital has not made a good faith effort to satisfy the requirements and they have not posted a machine-readable file or shoppable services file, that hospital will not receive a warning notice, that hospital will go straight to what we call a CAP phase or corrective action plan phase but it's only in the event that the hospital has not posted a machine-readable file or a shoppable services file.
So, the next action, of course, is what we just referenced which is a corrective action plan or a CAP. So, this document outlines the hospital's violation, the process or corrective actions the hospital will need to address for each deficiency, and the timeframe in which the violations must be addressed. When a hospital receives a request for corrective action plan or CAP of being out of compliance, we do ask again that it be acknowledged within five days of receipt. Now, the hospital must submit, within 45 days of the date of the request, the actual corrective action plan. CMS does have out on its website a template that can be used, it's a voluntary template for the hospital to actually respond with a CAP. After the 90 days, however, that CAP will be reviewed or the actions taken or what the hospital states that they will do to update their file.
Now, the CAP must be signed by the CEO or president or the individual that the letter was actually sent to. CAP should be submitted to the HPT compliance mailbox as identified here. And then, again, just to reiterate, CMS has made available a CAP template that the hospital can use in responding with the actions that they will take. Once that timeframe outlined in the CAP has passed, CMS will perform a review to determine if the violations have been addressed appropriately and to the regulation. Now, if for some reason, CMS determines that the violations are not resolved in accordance with the requirements of the CAP or a hospital is non-responsive to CMS's actions to address the non-compliance, the hospital may be subject to civil monetary penalties or CMPs.
Here you have the maximum daily CMP amount for the hospital with a bed count of 30 or fewer. And then, of course, you have the hospitals with at least 31 to 550 beds, the maximum CMP is $10 per bed per day. For hospitals greater than 550 beds, the maximum daily CMP amount is $5,500. Under this approach, for a full calendar year of non-compliance, the maximum total penalty would result in $109,500 per hospital and the maximum total penalty would be, I'm sorry, $2,007,500 per hospital. Now, this is in regulation and explained in the 40, I'm sorry, 45 CFR 180.90. Once CMS issues a CMP, CMS will post the notice of imposition of the CMP on the CMS website. Now, a hospital has 30 calendar days from the issuance of the CMP to appeal that decision. And in the CMP letter, it does provide guidance on how to appeal the decision.
So, let's talk a little bit about some other changes that happened with the calendar year 2024 OPBS ASC HPT compliance changes. CMS finalized several additions and modifications to enforcement provisions in the 45 CFR 180.7. CMS may require submission of certification by an authorized hospital official as accuracy and completeness of the data in the machine-readable file and submission of additional documentation may be necessary to determine hospital compliance. We are requiring hospitals to submit an acknowledgement at the warning notice stage, which I just reviewed. We ask that hospitals, when receiving their warning notice acknowledge that warning notice within five business days of receipt of that letter.
In the event that CMS takes action to address hospital non-compliance and the hospital is determined by CMS to be part of a health system, CMS may notify the health system leadership of the action and work with the health system leadership to address similar deficiencies for hospitals across the health system. CMS will publicize on the CMS website information related to CMS's assessment of hospital compliance, any compliance action taken against the hospital, and the status of such compliance actions and the outcome of such compliance actions and notifications sent to health system leadership. That website is up, this is the link to the website on CMS webpage that actually provides that information with regards to our actions taken in reference to our compliance with hospitals.
So, let's talk a little bit about the resources. I've mentioned several. I've mentioned landing page, the GitHub site, but I do want to go over and just make sure that we reiterate where you can go for these resources. So, communication with CMS. So, if you have received a notice of compliance from CMS, we do have an HPT mailbox, it is listed in those compliance letters received by hospitals. And as a policy matter, we just want to highlight, CMS does not discuss a hospital's compliance status with anyone except the CEO or president. However, that CEO or president can designate a representative on behalf of the hospital. The CEO or president can send an email to our HPTCompliance@cms.hhs.gov notifying CMS of the appointment of someone other than the CEO or president of the hospital as the official representative of the organization for hospital price transparency.
The email must either originate from the CEO or president's corporate email address or have an attached written designation signed by the CEO or president. It must include in the email the designee's name, email, phone number, and title, and any confidential information will be shared only with the hospital's official representative. All compliance inquiries should be submitted to HPTCompliance@cms.hhs.gov. And again, these are any of the compliance issues or responses to any of the compliance notifications that are provided to a hospital by CMS HPT team. This is the hospital price transparency webpage, www.cms.gov/hospital-price-transparency. There you'll find your frequently asked questions, 10 steps to a consumer-friendly display, and there's also a quick reference checklist that's available to all the hospitals on this webpage.
Now, in previous discussion and as we've gone through the slides, we've talked about the tools. Here you will find the tools that are available to all hospitals. As you can see, we now have an online validator for those that are using those templates that are required for July 1st of 2024, CMS has just uploaded a new tool, which is an online validator, to validate your template. In addition to explanation and assistance in technical direction, we have a CLI validator there that you can access, the MRF or machine-readable file naming wizard. and then you can also find the TXT file generator. All of this sits at the hospital price transparency tools webpage in addition to directing you to the GitHub site where you will find the templates and the data dictionary that's available for use with those CSV “wide”, CSV “tall” and the JSON.
Now, if you're not in a compliance status or if you just have a general question with regards to CMS HPT, you can email that question to Hospital Price Transparency Team which you will find on the HPT website, www.cms.gov/hospital-price-transparency/contact-us and there's also availability for someone to submit a complaint. But for hospitals that are not currently in a compliance status and are working with either a warning notice or whether it be a CAP and you just have a general question with regards to HTP, I'm sorry, HTP, you would submit that question to just email a question. Now, if you're in a compliance status, you would use the HPTCompliance@cms.hhs.gov which we provided you. But all of these resources are available at the HPT website on the cms.gov web page.
I want to first thank you all for sitting through the presentation, we will take questions and answers, provide Q&A. However, I do want to just point out, we will discuss any questions in general terms, we will not discuss specific hospital questions or issues. If you want to, you can submit those to the CMS HPT compliance web page and we'll be more than happy to answer those questions for you. But we will take any general questions with regards to our HPT program. I want to thank RHIhub and HRSA for providing us this opportunity and I think we'll open it up now.
Kristine Sande: All right, here is a question. Does CMS have a list of companies that can help hospitals prepare these requirements?
Carmen Irwin: No, CMS does not provide a list of companies. I would say that, if you're looking for assistance and you are a hospital, it may be beneficial to reach out to hospital associations or other associations that help hospitals in your state. If you're a small rural hospital, of course, maybe the State Offices of Rural Health or maybe NRHA, the National Rural Health Association, could direct you but CMS does not provide a list of companies to create or to prepare your machine-readable file.
I would like to just ... If I could reiterate, on that CMS GitHub website, we have provided step-by-step detail directions for those templates. In addition, you can always submit questions, we're more than happy to help and provide that technical direction. So, if a hospital does get started and is working to use those templates and finds themselves stuck or have a question, please feel free to use that platform of submitting your technical question or if you have a question in general. Our goal is, of course, to help all the hospitals come into compliance so we're more than happy to hear if there's something that is causing you maybe some grief or not understanding, that GitHub website does have the opportunity or provides the opportunity to a hospital to submit a question or concern or a technical question that maybe we can get you direction or help you get your file created.
And again, the validator tool was created for that to make sure that, as you're putting your file together, if you run that file within our validator tool, it will help you identify if you currently have any errors prior to submitting or uploading that file to your website.
Kristine Sande: It says, not sure if this is the right space but, as an advocate, we feel the JSON files are not accessible. Why is this one of the recommended file types and what's the best way for the general public to view these types of files?
Carmen Irwin: I don't have an answer for that, I would say that would be something I would submit as an email question. I don't have an answer why the JSON was chosen but I'm sure that, if you submit the question, we can get you an answer.
Kristine Sande: Thank you so much, Carmen, for this great information. And as I mentioned earlier, the slides used in today's webinar are currently available on the RHIhub website. Thank you again for joining us and have a great day.