CMS Hospital Healthcare Pricing Transparency Compliance

Slide 22 from CMS Final Rule

Since the CMS mandated pricing transparency on 1/01/2021, a multitude of vendors rushed to the market to help providers meet the new compliance requirements. Without meeting the compliance, hospital providers face penalties of $300 per day, per facility, that CMS plans to increase. These penalties will soon range from $109,500 to $2,007,500 per year, per facility and can go back retroactive to January first. With this rush to market, many vendors offered a product that publishes pricing based upon averages and aggregated or historical reimbursement for "negotiated" charges, which are not in compliance with the new final rules just published by CMS on August 11, 2021. This rule published on slide 22 brought clarity for the correct calculation methodology to be in compliance. Pricing cannot be averaged from historical claim data or reimbursement data, as it is not relative to the patient and their current insurance plan. To meet this mandate requires calculating that patient's payer contract down to the plan for an accurate price for that prospective patient. Dena Bates, President of Revenue Masters issued a response to the CMS ruling: "We have been telling hospitals for a while that many and maybe a vast majority of the pricing transparency vendors are not in compliance, including some big names, because they calculate from past averages for pricing to post. We know many large recognizable companies that are doing this. The only way to comply is to use a true contract management company that can model each contract down to the plan to post the correct compliant pricing. It takes more work, but that's what is necessary to meet the requirement."

Hospitals should check to ensure their pricing transparency is in compliance by asking their vendor whether the pricing they are posting was based on average aggregates or if they provided all of the payer contract to calculate compliant pricing.

Revenue Masters is one of the compliant firms utilizing contract modeling and offers full pricing transparency and contract management solutions.

Media Contact:  Rick Bengson - rick@revenuemasters.com