Proposed Changes to Hospital Price Transparency Rule: Radiology, Laboratory and Pathology Impacted

The Hospital Price Transparency Rule was introduced to help patients identify the cost of hospital items or services before receiving care.  Under the rule, hospitals are required to provide clear, accessible pricing information online in two ways:

• A comprehensive machine-readable file containing standard charges for all items and services provided by the hospital.
• A consumer-friendly list of standard charges for 300 shoppable services (including 70 CMS-specified and 230 hospital-selected) provided by the hospital.

To ensure compliance, CMS began auditing hospitals in January 2021 when the rule became effective.  Through the audit process CMS has identified that the majority of hospitals are not fully compliant with the Hospital Price Transparency Rule requirements. 

To assist hospitals in complying with the rule, CMS published proposed changes to the enforcement of the Hospital Price Transparency Rule as part of the 2022 Outpatient Prospective Payment System. 

Four key changes from the proposed rule are defined below.

Increased Monetary Penalty for Non-Compliance

CMS has highlighted concerns over a high rate of non-compliance particularly among larger hospitals.  To address this concern, CMS is proposing that beginning January 1, 2022, the current $300 a day penalty amount will increase related to hospital size.  For hospitals with 30 or fewer beds, the penalty will remain at $300 per day.  However, for hospitals with over 30 beds, the penalty will increase by $10 per day per bed with a maximum allowable penalty of $5,500 per day.

To date CMS has not implemented non-compliant monetary penalties and is focusing on issuing warning letters and providing 90 days for hospitals to address non-compliance before additional action is taken.   

Barriers to Access Machine Readable Files

The Hospital Price Transparency Rules requires hospitals to make the machine-readable file easily accessible, without barriers, and must ensure that the data may be digitally searched. Through their audits of hospital compliance, CMS has noticed hospitals are not making standard charge files accessible without barriers. 

Examples of methods used that presents barriers include:

• Common methods that prevent direct access to the data including anti-automation tools requiring users to prove they are human or requiring the user to act prior to viewing.
• Technology that hinders the findability of the webpage that contains links to hospital data.
• Application programming interfaces that obscure access to the data in a single machine-readable file.

To address this concern, CMS is proposing to update the list of activities that present barriers to access to the machine-readable file, specifically to require that the machine-readable file is accessible to automated searches and direct downloads. 

Clarifications on Price Estimator Tools

CMS indicates that some hospitals are not utilizing price estimator tools that meet the criteria outlined in the regulations.  For example, some tools produce an average payment amount versus the required single estimated payment amount specific to the individual.

CMS is clarifying that an online price estimating tool must provide cost estimates that take the individual’s insurance information into account and reflect the amount the hospital anticipates it will be paid.

Learn more about our Patient Estimator in this Video

Shoppable Radiology, Laboratory and Pathology Services

CMS defines the term shoppable services as:

• Services that can be scheduled in advance in a non-urgent situation, thus allowing the patient to price shop.
• Ancillary services provided in conjunction with a shoppable primary service.

The Rule requires hospitals to post standard charge information on 300 shoppable services, 70 of which are specified by CMS and the remainder can be selected by the hospital.  Of the 70 CMS-specified shoppable services, more than 25 are related to radiology and laboratory.

To learn more about the potential implications, watch the complimentary on-demand webinar “Price Transparency: Does it Change Your Lab Strategy?“