As of the end of 2023, more than 90% of hospitals have posted a machine-readable file of their pricing information and 83.1% posted substantial negotiation rates. Additionally, the number of payers posting data increased from 67 to more than 200. This comes after two years of changes, education, and enforcement from the United States Centers for Medicare and Medicaid Services (CMS) about price transparency regulations and requirements that initially went into effect in 2022.
However, while compliance has increased as time has gone on, 2024 will bring new requirements to the price transparency arena. One such change is that under the 2024 OPPS Final Rule, a required schema is now implemented for hospital machine-readable files and new required fields and accountability parameters are included.
January 2024
As of January 1, 2024, hospitals were required to add a footer link to their homepage that directs users to price transparency resources. In addition, the webpage must have a text file added to the root folder of the website that points to a download link for the current machine-readable file. CMS also published a tool and technical implementation guide for hospital IT departments to use to comply with all requirements.
Additionally, as of January 1, 2024, compliance actions (including warning notices that have been sent) or assessments may be publicized on the CMS website, not just a list of hospitals that received civil monetary penalties.
July 2024
A second set of updates is slated to start seeing enforcement as of July 1, 2024, mostly centered around standardizing the machine-readable files and additional reported fields. It seems to build off of the schema requirements with the goal of allowing CMS to pull credible data directly from the files. CMS will also update the instructions and data dictionaries included in the links above.
Additionally, payer-negotiated rates will need to be associated with the proper payer and plan as separate data elements in the files. While CMS says they are working to prevent files from becoming overly bulky due to the vast amounts of information (and possibly repetitive rates across different plans), each payer-negotiated rate must also be accompanied by a description of the contract provision used to calculate the rate.
Providers must also be able to elaborate on how each rate was calculated while creating their machine-readable files, providing enough information to ensure there is enough context to be able to compare rates.
January 2025
As of January 1, 2025, the requirements expand once again, with average expected allow amount rates and additional Part B drug reporting becoming part of the data set. It’s likely that as we get closer to the enforcement date of these requirements, CMS will provide additional guidance and resources.
Congressional Impact
It’s not just CMS and updated guidance that is continuing the discussion of price transparency and requirements. Congress has also gotten into the conversation, with various hearings held throughout the year to discuss compliance with and certain shortcomings of the current requirements. It is likely that Congress will continue to study – and perhaps legislate – additional transparency requirements for health care providers.