Hospital Price Transparency: What Hospitals Need to Know – Part 2

Date: Tuesday, October 15, 2024
Duration: approximately 60 minutes

Featured Speaker

Carmen Irwin, Health Insurance Specialist, Centers for Medicare and Medicaid Service

Beginning January 1, 2021, hospitals operating in the United States are required to provide clear, accessible pricing information online about the items and services they provide. This webinar will discuss the latest hospital price transparency policies effective January 1, 2024. The Centers for Medicare and Medicaid Services (CMS) subject matter expert will review the latest policy requirements and enforcement actions for hospital price transparency effective July 1, 2024 through January 30, 2025.

For more information on the first webinar in this series, see Hospital Price Transparency: What Hospitals Need to Know.

Additional Resource

From This Webinar

Transcript

Kristine Sande: Hello everyone. I'm Kristine Sande and I'm the program director of the Rural Health Information Hub. I'd like to welcome you to today's webinar, Hospital Price Transparency, What Hospitals Need To Know, Part Two. And now it's my pleasure to introduce our speaker for today's webinar. Carmen Irwin, Health Insurance Specialist, has been with the Centers for Medicare and Medicaid Services, Dallas Regional Office since 2002. She currently serves as the office of program operations and local engagement hospital price transparency team member. Carmen has worked with several Medicare contractors for both program integrity and Medicare policy. She has served as lead for provider relations, DME, POS, policy lead, Medicare part A and B policy areas, and rural health coordinator for the CMS Dallas Regional office. Carmen holds a Bachelor of science and political science and history from Francis Marion University in Florence, South Carolina. And with that, I'll turn it over to you, Carmen.

Carmen Irwin: Thank you, Kristine. Good afternoon and good morning to everyone. I would just like to say thank you to RHIhub and HRSA for collaborating with CMS today and getting this information out with regards to hospital price transparency. So this is just our disclaimer. We're going to, as of today, as of the time that I'm presenting this information, it's all up to date, but as things change in federal government and with CMS, we would just ask that you keep up with the listservs in our Medicare website to make sure that you're following any changes or updates with regards to HBT. So we're going to talk today about hospital price transparency. This is our second webinar in the series, and we're going to talk a little bit about where we are, where we're going and where we started.

So we'll get started with the initial hospital price transparency regulation, the introduction, where did we start? So back in January 1st, 2021, that is when the Hospital Price Transparency Regulation Section 2718e of the Public Health Service Act actually was implemented. And in that implementation, as of January 1st, 2021, all hospitals operating within the United States were required to make information available in two ways. That first way of course as a comprehensive machine-readable file or what we like to call it, an MRF, with all standard charges for items and services. In addition, the second way is as a display of standard charges for 300 shoppable services in a consumer-friendly format. In addition, this could also be what we call a PE tool, or price estimator tool, for the hospital. So in that initial implementation of the regulation, we had two requirements, the machine-readable file and the shoppable services tool.

So as of 2021, CMS moved forward with those requirements and with the finalization of the calendar year 2024, OPPS and ASC final rule, additional requirements were put into place. As of January of this year, the improving access to the hospital's machine-readable file also required that hospitals make a TXT file and a footer, and those requirements went into play January one of this year. That is of course, the requirement for the hospitals to have not only their machine-readable file, but now an automated or a tool for automation with regards to where that machine-readable file sits on the hospital's website.

Going a little bit further down our timeline, July 1st of this year, new data elements and format standardization was implemented with regards to CMS and HPT. This expanded that requirement to more of a standardized format for our templates or how the MRF, or machine-readable file, should look. This expanded the data set elements. And in addition, the requirement for templates to be used for each hospital to put their information out on their websites. And we'll go into a little bit further detail with regards to the templates and all the information and resources that come with it.

Now going forward, or looking ahead, in January 1st of 2025, there will be additional data elements that are required on the machine-readable file for hospitals. Just as a teaser, we have some information at the end of our presentation with regards to an upcoming webinar that's going to dig deeper into what those January 1st requirements will be.

So let's move into those items that we updated for calendar year 2024. One of those was improving the automated access to our machine-readable files. So improving the automated access as of January 1st, that requirement was the TXT file and the footer. And so this required that all hospitals must ensure that their public website, the public website it selected to host their machine-readable file, established and maintained in the form and manner specified by CMS, what we call a TXT file, in the root folder. This TXT file would have the hospital's location, name that corresponds to the machine-readable file, a source page URL, the source page to the machine-readable file, and then a direct link to the actual machine-readable file and hospital point of contact. This is all the information that was going to be required within that TXT file.

In addition, the hospital was required to put a footer or a link at the bottom of their webpage, and that footer would actually direct individuals to the publicly available webpage that hosts the machine-readable file. These requirements, of course, were put into process or put into implementation for improving that automated access. If you're looking for direction or assistance with regards to a TXT file or the footer, this information is available on CMS's website and we have instructions there. In addition, we have what we call a generator tool for the TXT file. All this information, again, available to the public, available to hospitals to access in addition to the tools, which we'll go over later in this presentation.

So let's talk a little bit about the template and the technical requirements. This was then put into play in July 1st of this year. So as of July 1st, hospitals' MRF must conform to the CMS template layout, data specifications and the data dictionary listed by CMS. So CMS has made available three non-proprietary formats, those being a CSV-tall, a CSV-wide, and a JSON template. CMS, in addition, created what we call a GitHub repository to house not only the templates, but also the data dictionary that provides technical instruction on how to fill out the templates, what data needs to go where within that template. How the hospital must encode the standard charge information in their machine-readable file's available there. And all this information is available out on our website at the GitHub repository.

In addition, there's a dashboard where hospitals and others can submit questions, if they have them, with regards to the machine-readable files or the templates. And there's also a place where information is shared with regards to the templates or that standard charge information and whether or not there are some questions or maybe information leading to an additional FAQ. We also have several FAQs out there with regards to questions that hospitals have brought to our attention with regards to the new templates or how to fill out the information or questions with regards to maybe some additional standard charge information and how to reflect that in the machine-readable file. So we're going to talk a little bit about not only the requirement for the templates and where to go to get that technical assistance, but some of the data elements and how they're set up within that template for the machine-readable file.

The data elements create context for hospital standard charges. So as you see on this slide, we have standard charge item and service information and then coding information. So this is how the hospitals would put that information into the template as shown in our data or GitHub repository with the data dictionary. Shows an overview of how it is encoded, or the data elements, according to the technical specifications described in our data dictionary.

The data elements are divided into five groups, as you see here. You have the MRF information, which is standard on that machine-readable file. Then you would have the hospital's information, then you would have the standard charges, the item in service information, and then coding information. There are a few items that are highlighted or have asterisks behind them. These are the items that are going to be required as of January 1st, 2025. But for the time being, all the other information is out there on our GitHub website and how to actually encode this information into those standard templates that are available on the GitHub website for CMS to actually fill in your machine-readable file. So there are three ways to display payer-specific standard charges, and we've listed them out here. All this information is on the CMS website. Again, in that GitHub repository with the data dictionary.

But as you see, we have a dollar amount, a percentage, or an algorithm. Now, the key here is that all this information must be identified in an actual dollar amount. So if payer-specific negotiated charges result in a variable dollar amount for members or a payer plan or a combination, then what we're looking for in that negotiated charge, as a percentage or algorithm, we still want estimated allowed amount in the dollars, not in a percentage, not in an algorithm. We're looking at actual dollar amounts. There are FAQs specific to how the payer-specific standard charges should be labeled or entered into that machine-readable file. In addition, we have several FAQs and examples on the templates so that hospitals understand how to put those standard charges in a dollar amount within their machine-readable file.

So we've talked a little bit about the introduction to the templates and the data dictionary. Again, I just want to bring your attention to the GitHub website that we've listed below. It is in your slides, very easy to access. All the information is out there. So that data dictionary, the GitHub repository and all the tools are available to hospitals by going to the GitHub website for CMS Hospital Price Transparency. In addition to the tools, we've put a little bit information here, just some bullets, and I want to go over these because I think it's very critical. If for some reason a hospital is new to these resources or to the GitHub repository, we have of course step-by-step. We ask that you review the resources first. What is out there? How should I use that to my ability? Then we say, "Select a template." You have three non-proprietary templates you can choose from. You have a CSV-wide, a CSV-tall or a JSON. And then for each one of those templates, follow the data dictionary.

That data dictionary goes step-by-step with the template, providing instruction, technical direction on how to put that information into the template. We have reference examples on our repository or GitHub website. In addition, we have not only the TXT file generator, we also have what we call our online validator. What that validator does, once the hospital puts their information into one of those three templates, you can actually put that file through the validator and it will spit out an outcome. That outcome would be whether or not you have those standard charges or the headers correct in the template. Now, it doesn't evaluate the template totally or encompasses a true review of your machine-readable file, but it does look at your machine-readable file if you test it on the validator to identify if you have errors in those standard charges or those headers for the template itself.

You can put your file through that online validator as many times as you want. You can actually get the output, go back, check those errors that it's spitting out to you. If there's an error that you get that you're not understanding, you can actually submit that question to us. We'll provide those email mailbox links for you later on in the presentation. But there are several tools that were built specifically by CMS to ensure that hospitals get the technical direction they need when setting up those machine-readable file. So again, just to show you, go step-by-step on our GitHub repository or website to show hospitals how to use the templates, how to use that data dictionary, we provide examples, and then of course, tools to test what you've created in your machine-readable file. So again, all this information is out there. I would urge any hospital that is in the process or maybe updating their information to really use those tools available to them.

So now that we've talked about where we came with HPT, or hospital price transparency, what the requirements are, what tools are out there for your use, we have to talk about the compliance process or where we come from a compliance output. That is where the team I work for and where we provide technical direction with regards to being compliant with HPT. Next slide. So how does it work? The compliance assessment is done originally by a team that reviews the hospital's machine-readable file. So during this comprehensive review, CMS assesses whether or not the hospital has disclosed their standard charges and whether that disclosure of the standard charges meets the requirements that we stated in the very beginning. Do you have a machine-readable file? Do you have your shoppable services? Do you have a PE tool, or price estimator tool?

So specifically, CMS assesses whether or not you've met the criteria, form and manner, that CMS has indicated on our requirements. The machine-readable file and the shoppable service file, or price estimator tool, are then evaluated based on compliance and whether or not they meet the regulatory requirements, the contents of the file, the file's accessibility, and the date of the last update. So how does this work? Once that initial review is done, CMS determines whether or not the hospital files are in compliance with the final rule. So what occurs is that if everything looks good and the file's complete, that file or that hospital is then sent on. Good to go, no issues. If for some reason a violation exists, CMS issues what we call a warning notice. And that warning notice must be acknowledged by the hospital within five days of receipt. We have five days highlighted here. The hospital receives a letter or a notice identifying those violations. In that notice, we ask that the hospital contact CMS via the hospital or via the HPT compliance mailbox and acknowledges that they have received that warning notice.

The hospital then has 90 days in which to come into compliance. Within that 90-day period, if the hospital needs any type of technical assistance, they can submit an email to the compliance mailbox saying, "Thank you very much for the notice. We're not understanding these violations." Or maybe they have a question because they felt like, we thought our file was complete. We then, CMS HPT compliance division, will provide technical assistance. At that 90 day mark, that file is re-reviewed to see if that hospital has come into compliance. There is a process that we start with the warning notice. However, if for some reason, on initial review of the hospital's file, it is determined that there is not a machine-readable file, we then actually issue what we call a CAP notice. That hospital does not receive a warning notice because there is no file out there that meets the requirements of CMS. So you can have an initial warning notice, or if for some reason the hospital does not have a machine-readable file, it would go straight to what we call a CAP phase, or Corrected Action Phase.

So in that next process, we have a continued enforcement. And that would be the Corrective Action Plan as stated before. After that 90 days of the warning notice, if CMS re-reviews or assesses the hospital's machine-readable file, shoppable service file, and it's identified that either not all the violations were corrected, or maybe some were, but some weren't, then we would issue what we call a Corrective Action Plan for being out of compliance with the Hospital Price Transparency Regulations. Hospitals, at that time, do receive an additional notice, that CAP notice. Again, we ask that the hospital acknowledge, within five days of receipt, via email that they've received that notice.

In addition, once that CAP notice is received, we ask that the hospital submit a Corrective Action Plan to CMS within 45 days of the date of the CAP notice. There is a template on our website that is for a CAP submittal. The hospital just needs to submit a Corrective Action Plan identifying what action they're going to take to correct each one of the violations that is listed in that notice. The 45-day mark is for the CAP submission. The hospital has 90 days which to come into compliance with those violations. That CAP that they submit on the 45th day, or before the 45th day, must be signed and dated by the chief executive officer or president, whoever that notice was directed to. And that notice needs to be submitted to the HPT compliance mailbox as identified here in this slide.

In addition, we have a CAP template available on the website which is listed here. And even in this process, if the hospital's still having issues, once they receive that CAP notice, they can reach out to the HPT compliance mailbox again and say, "We don't understand these violations. We're needing some technical assistance." CMS HPT compliance team will reach back out to the hospital and provide that technical assistance with regards to those violations. Once the timeline, as identified, has passed, CMS at that 90 day will re-review the machine-readable file and the shoppable services file for the hospital to determine if those violations have been addressed. If the hospital, at that time, has come into compliance, they would receive a closure notice. If for some reason that violation is still lingering or still out there, we would then take the next step with regards to our compliance enforcement.

That next step that we take after the CAP would be a civil monetary penalty. So if CMS determines that those violations are not resolved within accordance to the requirements of the HPT requirements for CMS, the hospital may be subjected to a civil monetary penalty. As you see here, we have broken down how that is determined with regards to the civil monetary penalty. The maximum daily CMP amount for hospitals with a bed count of 30 or fewer are $300 a day. For hospitals with at least 31 up to 550 beds, the maximum CMP is $10 a bed per day. And then for hospitals that exceed or are greater than 550 beds, the maximum daily CMP amount is $5,500. And under this approach, it's for a full calendar year of non-compliance. And then the minimum total penalty amount would be $109,500. The maximum penalty, as you see here, would be $2,007,500 per hospital. This is within our regulations.

Once CMS has issued a CMP, this will be posted. CMS will post this information of the notice of imposition of CMP on the CMS website. A hospital has 30 calendar days from the issuance of the CMP to appeal that decision. That appeals process is within that notice of imposition that the hospital receives and they must take the steps as listed in that notice. So with our compliance process, there were some changes that were approved, or regulations that were updated as of calendar year 2024 with regards to our compliance changes. We finalized these changes and modifications for enforcement were implemented. We've talked a little bit about what those were in the process of a compliance or our compliance process, but I'm just going to go over them. CMS may require a submission of certification by an authorized hospital official as to the accuracy and completeness of the data. Now, this is actually implemented in those templates that we spoke about previously.

There is a section within the template that states, and there's an actual acknowledgement statement within the template that the hospital must fill out when submitting that template or when putting it on their website. And that is necessary to determine the hospital compliance. CMS requires to submit an acknowledgement of receipt for the warning notice. We discuss this in the compliance process. Once you receive a warning notice, we do ask that the hospital acknowledge that warning notice within five business days of receipt, and that is to the HBT compliance mailbox. In the event that CMS takes action against a hospital for non-compliance or a hospital is determined by CMS to be part of a health system, CMS does reserve the right to reach out to not only the hospital leadership, but if that hospital is within a system, reach out to the system leadership to make sure that they take action to come into compliance. And that way, we can maybe address similar deficiencies that may be occurring within the system of the hospital.

CMS also implemented the publication of all actions taken within the Hospital Price Transparency Compliance process. So this information is now available on a public use file on CMS's website. The link below takes you directly to that website. This lists any compliance action taken by CMS to a hospital, whether it be a warning notice, whether it be a CAP, and of course CMP. All this information is posted on a quarterly basis and updated on the CMS website. And again, all this information can be accessed at the email listed, or the URL, listed below. So all these actions had been implemented with regards to the compliance changes for CMS as of fiscal year 2024.

So we've talked about how we come into play with HPT and the changes of HPT, or Hospital Price Transparency. We've talked about the new requirements. Those not only going into effect January of this year, and July, but those to come in January of 2025. And we've talked about the requirements with regards to our compliance process. I do want to just reiterate what resources are out there. So as you see here, we have the CMS Hospital Price Transparency data dictionary and GitHub repository, and we have the HPT website resources page. We also have a tools page. And that tools page is where all the information is listed for HPT. Here is a direct link to the website.

As you can see, we've listed all the hospital price transparency tools. We've listed the validator, the CLI online validator, our MRF naming wizard, and the TXT file generator. In addition, once you go to any of these, you can be linked back to our GitHub repository. So it's a great process, it's a great landing page. It's useful for all hospitals, and we urge you to go out there if you have any questions, concerns, or just want to take a look to make sure that your machine-readable file actually meets the standard requirements of the templates.

Here are the two ways in which you can contact us. Now, I want to definitely identify or delineate the difference between the mailboxes. So as it states here, those general questions, you can submit any general question for hospital price transparency to the pricetransparencyhospitalcharges@cms.hhs.gov. That's going to be your general questions with regards to hospital price transparency. Whether you have a question about filling out a template or questions specific to machine-readable files in general. That second mailbox that listed below are compliance questions. That is for actual hospitals that are in the compliance process. That is where you would submit your acknowledgments to not only a warning notice or a CAP notice, maybe you're requesting some technical assistance with regards to the notices that you've received. That second email box is where you would submit those questions or that information. In addition to if you have received a CAP notice, this is the mailbox in which you would send your CAP or your actual Corrective Action Plan to CMS as identified in the notice you receive.

So there's a slight difference with our mailboxes, but don't be discouraged, even if you send it to the wrong mailbox, we'll get it to the right place. We'll get your question answered or direct you to the right person to answer that question, whether it be a question about compliance or whether it be a question about general hospital price transparency. But we just wanted to identify that there are two separate entry ways with regards to hospital price transparency. You have the general questions, and those would be, again, your machine-readable files, something about the actual templates, whether you have a general question about how the complaints are submitted. And then those hospitals that are currently within the compliance process where you need to send your acknowledgments, where you need to send your CAP, or if you're just asking for technical assistance. So again, a great slide to keep, definitely reference if you have any questions or concerns with regards to hospital price transparency.

Kristine Sande: All right, thanks so much, Carmen. That was great information. JSON files, in many cases remain inaccessible for the general public and require either prior knowledge or some research on how to access and view. And even then, we've had limited success. Are there any guides to help address this or opt for CSV alternatives?

Carmen Irwin: And you'll have to forgive me, if a hospital does choose to use a JSON, there's nothing that CMS is requiring as far as having to use a CSV. I really don't have a specific answer for that, but we can take that question back and submit it and hopefully get you an answer. I don't know of any requirements that would change the view or the use of a JSON file at this time.

And if I could, while we're waiting on any questions, I do want to just... One of the items that I failed to mention when we were talking about requirements and the use of our resources. The one thing I do want to remind all hospitals, especially on this webinar, as you're making updates to your files to come into compliance with the annual updates, do remember that any links or URLs that you're using within your TXT file or on your footers, as you're making updates to your files, make sure that you're updating those URLs, because of course, when we use those links, we want to be coming to the most updated machine-readable file that the hospital has placed up on their website. So just lessons learned, we're getting a lot of checks and balances with that. So we do just want to make sure that as you're making those updates to your machine-readable file and coming into compliance, that you're also updating those URLs that direct back to that updated machine-readable file.

Kristine Sande: In reading what needs to be on the website, it's the CSV file as well as the TXT file, right?

Carmen Irwin: Correct. So the TXT file, as stated on the website, that needs to be in the root folder of the website that the hospital chooses to host the machine... That's in your root folder for the hospital. Your machine-readable file, of course, needs to be linked on the hospital's website where you're hosting that machine-readable file. I'm not technical, but if you go out to our TXT file generator, it goes step-by-step in the requirements. So do realize that the TXT file has to be in the root folder of the hospital website, whereas the machine-readable file, you're linking to the actual page where you're hosting that link or that file. If you have additional questions about that, you can submit those to that hospital price transparency email box.