Federal price transparency requirements for hospitals from the Centers for Medicare & Medicaid Services (CMS) provide patients with an unprecedented amount of insight into the costs for medical services.1
In theory, more pricing information should help individuals make informed choices about their care and contribute to a positive patient experience. However, the current reality is that many hospitals are not fully compliant with these requirements, and even for compliant hospitals, consumers may still not understand their likely out-of-pocket costs. This is because, unlike shopping for goods such as computer monitors, there are myriad factors that complicate what healthcare consumers may ultimately pay — specifically, uncertainties with future insurance adjudication such as progress towards deductible, copays, coinsurance, and out-of-pocket maximums. Additionally, navigating publicly available resources including machine-readable files of medical services as well as “shoppable services” can be cumbersome for consumers.
In 2022, the federal government ramped up enforcement actions against noncompliant hospitals, levying significant monetary penalties on two hospitals for failing to meet hospital price transparency requirements. Despite the difficulties of complying with price transparency, hospitals can take the following concrete steps to improve compliance, boost patient satisfaction, and mitigate the risk of potential CMS audits:
1. Ensure that publicly available pricing information, as well as information being delivered to patients, is complete and is not contradictory.
2. Meet the letter of the law, supplementing with additional pricing information whenever possible.
3. Promptly respond to CMS outreach to mitigate escalation and penalties.
4. Prepare for further action on price transparency in other domains.
Despite the difficulties and nuances with hospital price transparency, hospitals that champion price transparency can differentiate themselves from their competitors with tools that genuinely benefit the patient. With R1’s technology-enabled suite of revenue cycle management tools, as well as a team of dedicated regulatory compliance attorneys, R1 can be a strategic partner in enhancing the patient experience and promoting best practices.
One of those technologies, R1 Entri™ VisitPay, helps simplify and personalize the patient billing experience. As part of this solution, patients have one place to go to manage payments for themselves and their household, including a consolidated view of hospital and physician charges and explanation of benefits statements. In addition to complying with hospital price transparency, hospitals can empower patients to make informed decisions on their care using tools such as Entri™ VisitPay, which can result in greater patient satisfaction.
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1 This article focuses on the Centers for Medicare & Medicaid Services’ (CMS) federal price transparency requirements (referred to as “hospital price transparency”) located at 45 C.F.R. § 180.50 & 45 C.F.R. § 180.60
2 45 C.F.R. § 180.70(a)(2)(i)
3 See 45 C.F.R. § 180.70
Ogi C. Kwon, JD, MHA, is the Manager of Regulatory Affairs & Regulatory Compliance for R1 RCM.