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

The recent proposal introduced by the Centers for Medicare & Medicaid Services (CMS) on July 31, 2023, outlined significant changes to the Price Transparency initiative, specifically focusing on the machine-readable file (MRF).

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

CMS Proposal Highlights

The proposed 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.

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

Expanded Data Elements

The key focal point of this latest proposal revolves around the concept of Expanded Data Elements.

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 proposed changes introduce an array of new data elements that hospitals would be required to include in the machine-readable file (MRF), if finalized as proposed. These additions encompass both general and hospital-specific information, as well as enhanced data points corresponding to standard charges.

1. General and Hospital-Specific Information
   Hospitals will need to list their legal name, license number and address as well as include the file version of the CMS template and date of the most recent file update.
2. Enhanced Standard Charge Data Elements
   The proposed 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 with this proposal 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 Proposal Highlights

The remaining key aspects of the proposal 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 proposed changes and is dedicated to supporting hospitals in adapting to the evolving regulations. Many hospitals that have leveraged our Price Transparency machine-readable file are already compliant with existing requirements. In response to the proposed changes, we have taken a proactive approach, including:

1. Immediate Updates
   Making short-term updates to align with some of the proposed file requirements. These changes will ensure a smoother transition for hospitals as they work towards compliance.
2. Engagement with CMS
   Actively engaging with CMS, providing comments and specific contract verbiage to seek further guidance and clarification on proposals that require more significant adjustments.
3. Strategic Planning
   With the final ruling set to be published by Nov. 1, our team is strategically planning its implementation strategy to ensure readiness by March 1, 2024, the compliance deadline. This approach allows 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 proposal underscores the importance of machine-readable files and their role in empowering patients to make informed decisions about their healthcare.

As you familiarize yourself with the proposed changes, we encourage you to publish your comments on the rule on the CMS website. These are invaluable in shaping the final regulations and ensuring they reflect the diverse needs of the healthcare industry.

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.