On November 1, 2023, CMS released its final rule for the 2024 Outpatient Prospective Payment System, which contained new pricing transparency requirements for hospitals. 通过这些新规定,CMS通过提高信息披露要求,表明其对价格透明度的重视, standardizing data formats to facilitate aggregation by third parties, and stepping up its oversight and enforcement efforts. 尽管自2021年生效以来,该行业在接受定价透明度要求方面进展缓慢, it is now clear that a strategy of avoidance will not remain viable for long.
Background
对医院定价透明度的要求源于当时的总统唐纳德·特朗普于2019年6月签署的一项行政命令,并援引《bet8娱乐》作为其立法权力的来源. 同年11月,CMS发布了第一套拟议规则, with final rules taking effect January 1, 2021. 这些规定要求医院在其网站上提供两套价格数据. 第一组是300项“可购买bet8娱乐”,旨在让消费者直接比较医院之间的bet8娱乐成本. 第二组是包含医院提供的所有项目和bet8娱乐的综合价格的机器可读文件(mrf). 这些文件旨在方便第三方下载、汇总和传播.
The industry as a whole was slow to embrace the new requirement, and many took minimal or no steps to comply in 2020 for a variety of reasons:
- Hospitals had serious reservations about making their negotiated rates public.
- Many considered the requirement to be of questionable legality, 美国医院协会发起了一场不成功的诉讼,要求废除该法案.
- 在整个2020年,COVID大流行几乎成为该行业的首要任务.
- 谁将在2020年当选总统,乔·拜登是否会当选,存在相当大的不确定性, should he win, would make pricing transparency a priority.
- 违规的处罚相对较轻,每天300美元(每年109,500美元)。.
Despite the industry’s hesitations, 拜登政府已经表明了确保价格透明成为现实的决心, 首先是在2022年大幅加大对违规行为的处罚力度,现在又增加了对综合文件的新要求,这些文件似乎旨在促进这些数据的汇总和传播.
Summary of New Rules
The CY 2024 rule contains quite a few new reporting requirements, several of which take effect on January 1.
- 首先,医院必须真诚地努力满足CMS的报告要求. It is unclear what this accomplishes, since actual compliance, and not just a good faith effort, is what regulators typically look for.
- CMS还要求医院在其网站上发布某些信息,以帮助用户浏览价格透明度信息,并提供医院的联系信息.
更实质性的要求将于2024年7月1日生效,并涉及全面的MRF. They include the following:
Additional hospital information
MRFs will have to include information about the hospital being reported, such as its name and license number. 起初,这个需求似乎是不必要的,因为用户可能已经知道了这些信息, having found it on the hospital’s website. However, 将这些信息包含在文件中,将有助于对大量医院的数据进行汇总, which appears to be the intent.
Information on payment methodologies
Until now, CMS had only required hospitals to report their negotiated rates, expressed as dollar amounts, for items and services; CMS was not concerned with the methodology for determining those amounts. Beginning in July, 医院需要将这些信息表示为费用的百分比或其他适用的算法, along with the historical amount paid for those services. 实际上,这允许第三方重建付款人的付款方法.
Attestation
In addition to the price-related information, 医院的指定代表将需要提供一份证明,证明MRF中包含的所有信息都是他们所知的完整和准确的. CMS认为,这将更好地加强问责制,并解决有关提交数据的任何悬而未决的问题.
Increased enforcement
Beginning in 2024, CMS将保留对医院标准收费信息进行全面合规审查并公布审查结果的权利, 以及针对医院采取的任何合规行动以及发送给bet8网站备用领导层的任何通知. This is in addition to the audits that CMS currently performs, 自该计划首次实施以来,哪些项目的数量显著增加.
Cross-referencing to insurance price transparency data
Lastly, while not a part of the new rule per se, 值得注意的是,保险透明度数据为CMS提供了一个额外的数据源,用于验证医院发布的数据. CMS可以使用这些数据来验证医院的数据是否包括其协商费率的所有计划, encompasses all items and services, and that the rates reported are accurate.
Implications for Hospitals
对医院来说,最紧迫和最明显的暗示是,这一要求将需要付出相当大的努力来遵守——不遵守将不再是一种选择. Not only has CMS stepped up its efforts to identify violators, it has raised the stakes for being found out, which will include public disclosure of the individuals responsible. 显然,这不是大多数医疗高管想要的新闻.
A second implication is that the rates published by hospitals, coupled with the pricing information that health plans must now make available, 会对供应商与付款人谈判合同的方式产生重大影响吗. Overall, 这可能会对费率产生进一步的下行压力,因为消费者有能力识别和选择成本较低的供应商. Similarly, payers will have greater ability to see what their competitors are paying, 而那些支付相对较高利率的公司将努力将利率降低到竞争对手的水平.
To manage these effects, 供应商将需要在如何定价bet8娱乐方面变得更加老练和有策略. It may no longer make sense to seek across-the-board rate increases; instead, 医院将需要确定哪些bet8娱乐是定价具有竞争力的商品,哪些是差异化的商品, allowing the hospital to command a premium price. And for the latter category, 医院需要做好准备,用质量和安全方面的确凿数据证实自己的立场, outcomes, and the patient experience.
ECG experts can help your organization navigate the requirements.
Edited by: Matt Maslin
Published December 20, 2023