Navigating CMS Updates: Adapting to Evolving Healthcare Machine-Readable File Regulations

The recent requirements introduced by the Centers for Medicare & Medicaid Services (CMS) on November 22, 2023, outlined significant changes to the Price Transparency initiative, specifically focusing on the machine-readable file (MRF).

These changes reshape how hospitals disclose pricing information, potentially impacting operations and compliance strategies.

CMS Requirement Highlights

The changes set forth by CMS aim to enhance transparency in healthcare pricing, empowering patients by providing information needed to make informed decisions about their medical care and increases competition among healthcare providers to lower costs.

Beginning January 1, 2024, each hospital must make a good faith effort to ensure that the standard charge information encoded in the MRF is true, accurate and complete as of the date indicated in the MRF. 

Let's delve into the details and understand the steps necessary to approach each item.

Expanded Data Elements

The key focal point of the latest requirements revolves around the concept of Expanded Data Elements which must comply before July 1, 2024.

CMS believes that a more comprehensive view of hospital pricing practices is crucial for patients to fully understand their healthcare costs. To achieve this, the requirements introduce an array of new data elements that hospitals must include in the MRF. These additions encompass general and hospital-specific information and enhanced data points corresponding to standard charges.

1. General and Hospital-Specific Information
Hospitals must list their legal name, license number and address(es) and include the file version of the CMS template and date of the most recent file update.

2. Enhanced Standard Charge Data Elements
The expanded data elements encompass various facets of standard charges, including:

• Type of Contracting Methodology

• Consumer-Friendly 'Expected Allowed Amount'

• Billing Class

• Drug-Specific Information

• Common Billing Codes

• Additional Billing Information

CMS believes these expanded data elements not only offer patients a clearer picture of healthcare pricing but also promote a higher degree of accountability and transparency within the healthcare industry.

Additional Highlights

The remaining key aspects of the requirements include:

1. Adoption of CMS Templates JSON Schema or CSV Format
Hospitals will be required to adopt one of the three CMS Templates: JSON schema, CSV (Wide), or CSV (Tall). This change aligns with CMS's commitment to standardizing data formats for easier machine readability.

2. Inclusion of a .txt File with Web Link
Hospitals must include a .txt file in the root folder of the MRF, containing a direct link to a publicly available web page hosting the MRF. This link, labeled "Hospital Price Transparency," ensures patients can easily access pricing information.

3. Introduction of New Definitions
The proposal introduces new definitions to clarify terms such as "Consumer-friendly expected allowed amount," "Encode" and "Machine-readable file." These definitions provide clarity and consistency in understanding the terms.

4. Affirmation of Inclusion of Standard Charge Information
Hospitals will be required to provide a statement affirming they have included all applicable standard charge information to the best of their knowledge.

5. Enhanced Enforcement Measures
CMS proposes a tiered enforcement approach, including written warning notices, corrective action plans and Civil Monetary Penalties (CMPs) for non-compliance. The maximum daily dollar amount for a CMP is $300, potentially resulting in significant penalties for prolonged violations.

FinThrive's Approach

FinThrive recognizes the significance of these required changes and is dedicated to supporting hospitals in adapting to the evolving regulations. Our Price Transparency MRFs are already compliant with existing requirements. In response to the changes, we have taken these steps:

1. Immediate Updates

• We've swiftly implemented the newly required format, ensuring alignment with proposed file requirements.
• Hospitals are encouraged to review our FAQs, ensure their CDM tables are uploaded into Contract Management and run their reports. These changes facilitate a smoother transition towards compliance.

2.Engagement with CMS

• We're actively collaborating with CMS, providing comments and specific contract verbiage to seek further guidance and clarification on proposals requiring significant adjustments.

3. Strategic Planning

• Our team is strategically planning its implementation strategy to ensure readiness by the July 1, 2024 compliance deadline.
• This proactive approach enables hospitals to navigate the changes seamlessly and with minimal disruption.

For hospitals, it’s crucial to maintain compliance and provide transparent pricing information to patients. This recent CMS ruling underscores the importance of MRFs and their role in empowering patients to make informed decisions about their healthcare.

At FinThrive, we’re committed to supporting hospitals in understanding these year-end updates and beyond. Learn more about how you can partner with FinThrive to navigate compliance with confidence or reach out to if you need help with generating your MRF.