The Centers for Medicare & Medicaid Services (CMS) has issued its final rule requiring hospitals to publish prices for services beginning in 2021. Under the rule, hospitals must disclose prices in a machine-readable format and on a searchable platform. The machine-readable file must contain “standard charges” for all services, including supplies and professional services. Standard charges include gross charges, discounted cash prices, payer-specific negotiated charges, de-identified minimum negotiated charges, and de-identified maximum negotiated charges.
The searchable platform must contain payer-specific negotiated charges for “shoppable services” and charges for ancillary services customarily provided with the shoppable service. Shoppable services are services that a consumer can schedule in advance, such as x-rays, outpatient visits, imaging, and laboratory tests. The charges must be published in a prominent and searchable location online or, when requested, in written form. Descriptions of care or the service must also be provided and must be described in plain language.
CMS will enforce compliance by evaluating complaints, reviewing reports of noncompliance created by third parties, and performing audits. Noncompliance may cause CMS to issue a warning notice and/or seek a corrective action plan, depending on the materiality of the violation. CMS may impose a civil monetary penalty (CMP) for a violation or in an instance where CMS requests a corrective action plan and a hospital does not respond. CMS may also impose a CMP if a hospital does not follow a corrective action plan. A CMP cannot exceed $300 per day, regardless of the number of violations, and will be publicized on the CMS website. And a CMP must be paid within 60 calendar days after the notice of imposition, unless the hospital timely appeals.
Hospitals may appeal CMS’ determination by requesting a hearing before an Administrative Law Judge (ALJ) within 30 calendar days of the notice of violation. If the hospital does not timely appeal, then the CMP is imposed, and the hospital loses the right to appeal “subsequent penalties pursuant to continuing violations.” In determining the reasonableness of a CMP, an ALJ may only consider evidence in the record relating to materials the hospital timely submitted to CMS (before the hearing) and the hospital’s posting of its standard charges, if available. The Administrator of CMS may review the ALJ’s decision. A hospital may also seek a judicial review after the administrative process is exhausted. Unless a hospital can show good cause, it has no right to appeal a penalty if it did not request a hearing. After the appeal process has been exhausted, any imposition of a CMP must be paid within 60 calendar days after the final decision.
The rule is downloadable at: https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf