New Requirements for 2020
With surprise billing still on the minds of lawmakers and regulators alike, CMS introduced the most comprehensive price transparency requirements to date in the CY 2020 Outpatient Prospective Payment System (OPPS) & ASC Proposed Rule in July 2019. Attempting to rectify the ambiguity of past guidelines, CMS proposed concrete definitions, public-facing posting requirements and new enforcement tools. Despite significant opposition to the proposal from a number of stakeholder groups, CMS finalized the requirements in the final rule released November 15.
Of note, CMS finalized a definition of “standard charges” that includes gross charges, the discounted cash price, the payer-specific negotiated charge, or the de-identified minimum or maximum negotiated charge. Each of these charges, as well as a description for each item or service, must be displayed prominently in an easily accessible, clearly identified, publicly available website. CMS also finalized a broad definition of “items and services” covered under the rule, stating that all items or services “that could be provided by a hospital to a patient in connection with an inpatient admission or outpatient department visit for which the hospital has standard charge” must be disclosed.
CMS and commenters anticipated that the above information could prove unwieldy, with long lists that would not be useful for the majority of healthcare consumers. Because of this, CMS created an additional requirement that hospitals disclose payer-specific negotiated charges for a much smaller set of common “shoppable services.” CMS defines a “shoppable service” as a service that can be scheduled by a consumer in advance, and hospitals must make public prices for at least 300 such services, as well as a plain language description of each service to aid patients.
Finally, CMS asserted its authority as the oversight body to monitor hospital compliance under the new requirements. CMS will evaluate complaints against hospitals as well as perform random audits of hospital websites. Hospitals that are found to be noncompliant will be notified and given an opportunity to create and execute a corrective action plan. Further failure to comply may result in the imposition of a civil monetary penalty up to $300 per day.
Anticipating pushback as well as time needed to implement compliance plans, CMS has set an effective date of January 1, 2021. A number of hospital groups already have announced plans to file legal challenges in opposition. Review a fact sheet on the rule and the full final rule text.
For more information, please write Alex Taira, ASCA’s regulatory policy and research manager.