CMS Releases Medicare Outpatient and Ambulatory Center Prospective Payment Final Rule, Includes New Transparency Requirements

CMS finalized Medicare payment rates for hospital outpatient and Ambulatory Surgical Center (ASC) services for calendar year 2024. Issued annually, this regulation traditionally sets payment rates for hospital outpatient departments and ASC services, as well as update policies related to reimbursement, coding and other areas. In this year’s final rule, CMS also included several provisions on enforcing hospital price transparency requirements.

As of January 1, 2021, all hospital systems are required to keep on their websites clear, accessible pricing information about the items and services they provide. This pricing information is required to be stored in a machine-readable format as well as an easy-to-read, consumer-friendly format. The goal of these requirements is to enable patients to compare prices and promote competition in healthcare markets. However, as of July 2023, only 36 percent of providers complied fully with this rule. While the majority of hospitals have posted files, most hospitals’ files are not considered compliant because they are incomplete, illegible, or the prices posted are not clearly associated with both payer and plan.

The hospital price transparency machine-readable file (MRF) is a single digital file intended to be read by machines able to process hospital standard charge information. CMS is finalizing new changes to increase standardization of this MRF to help deliver on the promise of hospital price transparency. Standardization will ideally improve hospitals’ ability to comply, enhance the public’s ability to aggregate information (for example, for use in consumer-friendly displays) and streamline CMS’s ability to enforce the requirements.

The agency finalized the requirement for hospitals to display their standard charge information by conforming to a CMS template layout, data specifications and data dictionary. The CMS templates will be offered in a comma-separated values (CSV) “wide” format, a CSV “tall” format and a JSON schema, similar to the sample templates that are available on the CMS hospital price transparency website for voluntary use since November 2022. The hospital will be required to encode its standard charge information in the CMS templates and conform with other specified technical instructions that will be made available in a data dictionary. 

CMS also finalized two changes that would permit automated access and real-time centralization of the files and standard charges data, including: a requirement that hospitals place a “footer” at the bottom of the hospital’s homepage that links to the webpage that includes the MRF; and a requirement for hospitals to ensure that a .txt file is included in the root folder of the publicly available website chosen by the hospital for posting its MRF. The .txt file must identify the URL for both the MRF and the webpage that contains the link to the MRF. CMS believes these requirements will improve the automated accessibility of hospital standard charges information and streamline CMS enforcement of the requirements.

Regarding enforcement of price-transparency regulations, CMS finalized several regulatory additions and modifications to its enforcement provisions. Under certain circumstances, CMS will be requiring submission of certification by an authorized hospital official as to the accuracy and completeness of the data in the MRF and submission of additional documentation as needed to determine hospital compliance. The agency will also now mandate hospitals submit an acknowledgement of receipt of the warning notice in the form and manner and by the deadline specified in the notice of violation issued by CMS to the hospital.

In the event CMS takes action to address hospital noncompliance and the hospital is determined by CMS to be part of a health system, CMS may notify health system leadership of the action and may work with health system leadership to address similar deficiencies for hospitals across the health system. Additionally, CMS may publicize information related to CMS’ assessment of a hospital’s compliance, any compliance action taken against a hospital, the status of such compliance action and the outcome of such compliance action, and notifications sent to health system leadership.

Source: National Association of Benefits and Insurance Professionals