Medicare Compliance & Reimbursement

Tip: Coordinate across departments for informed decision making.

Time flies when you’re caring for patients and adapting your procedures to new policies in the here and now. But changes like those in the hospital price transparency rule are an immense undertaking and likely will require months of preparation to avoid the censure of federal enforcement.

Reminder: The Centers for Medicare & Medicaid Services (CMS) issued a final rule and a proposed rule in the Federal Register last November, requiring hospitals to list the charges of 300 items and services online for patients — starting Jan. 1, 2021 (see story p. 33).

The “transparency announcement may be a more significant change to American healthcare markets than any other single thing we’ve done, by shining light on the costs of our shadowy system and finally putting the American patient in control,” said HHS Secretary Alex Azar in a release.

Remember, “this rule only applies to hospitals, which is defined broadly based on state licensure. The rule will not apply directly to physicians or physician groups unless the physicians are employed by a hospital subject to the rule,” points out attorney Benjamin C. Fee, with Hall, Render, Killian, Heath & Lyman, PC in the Denver office.

Fee suggests the following five steps for hospitals subject to the rule:

1. Start preparing now. Many pieces of the puzzle must be in place for this to be a success, from what shoppable services your hospital will choose to list to the systems you’ll use to make the list available in a readable format to patients — so don’t delay. “This is going to be an enormous lift for most organizations,” he explains. “While the text of the rules is fairly straightforward, applying the requirements to the complex and highly individualized world of hospital charges is going to create a lot of questions and hurdles that need to be addressed.”

2. Devise a plan of action. If your organization is impacted by the final rule, coordination and planning will be vital to ensure you’re in compliance with the stipulations. “Identify and form a committee or group of both individuals within the organization and outside resources to begin developing a work plan for how the hospital will comply with the new requirements,” Fee instructs. “This group may include individuals from revenue cycle, finance, billing and coding, legal and clinical.”

3. Review the requirements outlined in the rule. “There is a lot to unpack in the final rule. This is not as simple as taking the existing charge master and expanding it to include payer-specific negotiated rates,” Fee warns.

4. Analyze and evaluate payer contracts. It’s always a good idea to look over contractual relationships with payers, but in light of the rule, it is critical that you know agreed-upon services and rates upfront. “Begin pulling and reviewing the various payers the hospital is contracted with and the rates each payer has agreed to pay the hospital for the items and services the hospital provides,” counsels Fee.

5. Determine your list of shoppable services. Though CMS mandates a list of 70 required services you must list, there’s some wiggle room with the other 230 needed to round out the 300 shoppable services the rule requires. “Review the list of CMS-specified shoppable services and identify 230 additional shoppable services the hospital will make available in a consumer-friendly format,” Fee says.