OR Manager August 2023 - 22

Finances
Hospital price transparency rule
A year before the No Surprises Act (NSA), the
Centers for Medicare and Medicaid Services
(CMS) rolled out the Hospital Price Transparency
rule, which went into effect January 1,
2021. Although the NSA and the Hospital
Price Transparency rule are two distinct laws,
they both address price transparency.
The Hospital Price Transparency rule requires
hospitals to post standard charges as
a machine-readable file and in a consumerfriendly
format. The compliance rates have
been low. As reported by the Journal of the
American Medical Association, a random
sample of 100 hospitals in March 2021
showed that only 33% reported the negotiated
commercial prices for some services.
Another sample in September 2021 revealed
more than 50% of the 5,239 CMS-registered
hospitals did not post a machine-readable
file or display any shoppable services.
CMS has doled out fines to hospitals that
fail to meet these requirements. Most recently,
on April 19, it fined Frisbie Memorial
Hospital (Rochester, New Hampshire)
$102,660 and Kell West Regional Hospital
(Wichita Falls, Texas) $117,260 for violating
federal price transparency laws. In June
2022, Northside Hospital (Atlanta) was fined
$883,180, and Northside Hospital Cherokee
(Canton, Georgia) was fined $214,320. As
of April 2023, CMS had issued more than
730 warning notices and 269 requests for
corrective action plans.
desk staff have to explain the financials
to patients, and that drives up the
costs for the facility, which now has
to hire an extra person who is highly
trained and highly skilled to negotiate
with a patient. These negotiations can
be emotionally charged, " he adds, " and
it just makes the whole system more
inefficient. "
It is still too early to know all the
impacts of the NSA and Hospital Price
Transparency rule on consumers and
the healthcare industry. Dr Patel be22
OR
Manager | August 2023
In a letter to CMS dated March 4, 2022,
the American Hospital Association (AHA)
cited underestimated burdens and many barriers
that hospitals and health systems are
facing regarding the NSA.
Key concerns cited by AHA include:
➤ Administrative burden. AHA estimates
that each GFE would take 10-15 minutes
to generate, above what CMS
projected. Because of the individualized
nature of the estimates, automation
is not likely, leaving hospitals and
health systems strained with staffing
requirements to complete this task. This
burden may get even greater once patients
start using the patient-provider
dispute resolution process. As frontline
staff spend more time generating
and explaining GFEs, it takes longer to
complete the pre-registration process,
impacting patient care.
➤ Co-provider and co-facility requirements.
Previously scheduled to go
into effect in January 2023, this ruling
requires GFEs to include costs from
co-facilities and co-providers. AHA
contends that lacking a technologysupport
system, provider-to-provider
and facility-to-facility communications
and transactions are not feasible. In
its Guidance on Good Faith Estimates
for Uninsured (or Self-Pay) Individuals,
CMS announced it has delayed the
lieves the laws help educate providers
on the cost of care and reduce the
number of cases billed for unreasonable
amounts. Richberg sees this as an
educational opportunity for patients to
understand their care costs and make
informed decisions.
" Payors are catching on that certain
services can be done cheaper elsewhere
and will negotiate contracts differently, "
observed Fawn Esser-Lipp,
BSN, MBA, CNOR, CASC, CRCST, executive
director of The Surgery Center
enforcement of the NSA requirement
to include cost estimate information
from co-providers and co-facilities in
the GFE.
➤ Insurance status verification. Timely
GFEs require real-live eligibility and
patient-specific checks with insurers,
which are more costly than the traditional
batch transactions. AHA recommends
that procedure-specific insurance
verification be removed and
" group health insurance " be used instead.
➤
Patient-provider dispute resolution
threshold. The current ruling allows
patients to file a dispute if their bills
are more than $400 different than the
GFEs they receive. Although this is a
large amount for many patients, $400
is a low threshold and easily crossed
because of changes in complex cases.
AHA asked CMS to use the 10% excess
amount over the GFEs instead.
➤ Alignment between Hospital Price
Transparency rule and GFE requirements.
The two sets of rulings are not
designed to support each other and require
different workflows, creating inefficiencies.
AHA proposes that the rules
be reviewed and duplications removed
to align the requirements.
Sources are provided under References.
LLC, Milwaukee, Wisconsin. " For this
to really be beneficial, patients need
to realize they are consumers not just
receiving a service; they are paying for
a service. " Once patients get used to
the idea of shopping for medical care
and comparing costs, the demand will
rise, putting even more pressure on
providers, facilities, and health plans to
provide what is covered under the laws,
she says.
The Hospital Price Transparency rule
and NSA are relatively young; data are
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OR Manager August 2023

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