The Centers for Medicare & Medicaid Services (CMS) is looking to expedite enforcement and support large-scale data aggregation with new price transparency rules.
The 2024 Outpatient Prospective Payment System (OPPS) final rule, issued on November 2, 2023, builds on existing rules to promote the standardization of hospital data and make it more efficient to aggregate once posted. CMS is also setting the stage for more strenuous enforcement activities.
New Record Formatting Standard
The new rules establish standard machine readable file (MRF) templates that hospitals must use. Hospitals will have the option of formatting files using either JSON or CSV formats but must use one of the prescribed formats. These new templates include data elements that weren’t required previously, intended to facilitate the use of this price transparency data by tool developers and data aggregators.
New data elements include the contracting method along with applicable codes such as CPT, DRG, and NDC, along with quantity and unit of measure for pharmacy items. To help hospitals deploy these new templates compliantly, CMS will produce a new mandatory data dictionary and has created a validation tool.
Risk and Enforcement
In the past, CMS has only publicized the names of hospitals that don’t remedy any issues via an agreed upon corrective action plan. Under the new regulations, CMS can begin publicizing hospitals that CMS assesses to be noncompliant, even if it’s an inadvertent error and they intend to comply with the transparency rules.
This, combined with the requirement that hospitals affirm that files are true, accurate, and complete, increases the risks even in minor issues for hospitals, and signals that CMS will be taking a hard line on enforcement. In April 2023, CMS significantly increased the volume of hospitals they were manually reviewing for compliance, and are indicating with this rule they intend to increase the automation of their reviews, which will allow them to significantly increase the volume of reviews.
Standard Should Support Automation
In addition to creating a pathway to communicate with health system leaders, as opposed to strictly hospital CEOs, these rules also indicate that CMS will ask hospitals to establish an authorized official in cases where they’re assessed to be out of compliance with the rules.
To date, not only have the MRF file formats been inconsistent, but other posting details such as location and timing have been inconsistent, which has made automated gathering of these files more complicated.
These rules establish two new requirements intended to support this automated data gathering. In addition to the charge level information, files will also need to contain the hospital’s name, license number, and location name and address, along with the file version and the date when the file was last updated.
Hospitals are also required to include a direct link to the MRF in a TXT file in the root folder of the hospital’s website and in a footer on the hospital’s homepage.
Timeline for New Requirements
The new requirements begin rolling out in January 2024, and continue through January 2025. The website TXT file and footer link are required by January 1, 2024. The new templates, including hospital information, are required by July 1, 2024, other than the elements delayed until January 1, 2025, such as the estimated allowed amount, drug unit and type of measurement, and modifiers.
What hospitals should do:
- Analyze new requirements and perform a gap analysis.
- Work with your existing MRF vendor, or your existing internal team, to begin creation of MRFs using the new templates.
- If you’re due to update your MRF prior to July 1, continue the process to update if it’s possible you may not have the new template complete by the due date.
- Determine the process and responsibilities to affirm the accuracy of files by July 2024.
- Take time now to determine roles and approaches to be ready when enforcement issues arise, including designating an authorized official.
- Perform a complete assessment of your approach before the new templates are required in July 2024. If you don’t have the expertise in-house, find a vendor to assist with this effort.
- Look beyond compliance. Explore how you can use price transparency to boost your patient centricity efforts.
We’re Here to Help
For assistance with assessing your compliance, implementing these new regulations, or developing a patient-centric price transparency strategy, contact your Moss Adams professional.