CMS Delays Enforcement of Price Transparency Non-Compliance Penalties

Price Transparency Non-Compliance Penalties

In major progress! The Centers for Medicare & Medicaid Services (CMS) has delayed enforcement of key parts of a major insurer price transparency rule by six months until July 1, 2022. This announcement was made to give hospitals more time to comply with the transparency rules.

According to the latest announcement made by the federal agency: CMS understands that making machine-readable files available in the form and manner according to the rules requires a considerable amount of time and effort too. The concerned authorities made it clear that from July 1, 2022, the departments will begin enforcing the requirements. That hospitals are bound to provide clear, accessible pricing information related to in-network rates. And out-of-network allowed amounts as well as billed charges for plan years, available online.

Even though the rule goes into effect on Jan. 1, 2022, CMS will not enforce penalties to the hospitals. That fails to comply with the Transparency rule until July 2022. “Until regulations or further guidance is issued, the departments strongly encourage plans and issuers to start working to ensure that they are in a position to be able to begin reporting the required information with respect to 2020 and 2021 data by Dec. 27, 2022,” the guidance said.

The guidance comes after the U.S. The Chamber of Commerce and the Pharmaceutical Care Management Association (PCMA) challenged price transparency in court in separate lawsuits.

The Proposed Rule

Patients in the United States believe that_getting treatments or surgery even with health insurance isn’t less than stepping into a financial black hole. The major reason is the lack of transparency in payments. As the majority of the healthcare facilities don’t give an appropriate estimate about; how much of the medical bill will be covered by the insurance companies? How much of it will be collected by the patients? It remains a mystery until the healthcare services are being rendered.

Most of the time it results in unexpected medical bills that hold patients back from fulfilling their financial responsibilities. For example, if patients receive a medical bill, higher than their rough estimate. Then it might disturb their budgets and end up with delayed copays, deductibles and out of the pocket expenses.

However, while keeping in mind this inconvenience, the Trump administration had issued the payment transparency rule in October 2020. That was going into effect on January 1, 2022, with a phased implementation through 2024. However, it is difficult to decide: whether it is a sigh of relief for the hospitals. Or unfortunate that healthcare consumers will have to wait a bit longer for improved price transparency.

Because the Biden Administration has delayed the enforcement of certain provisions of the transparency rule. After recognizing the concerns of the healthcare providers across the United States. The federal agency strongly believes that the enforcement of price transparency non-compliance penalties will eliminate the patients’ financial hardships. It will take the healthcare industry towards more integrity and transparency as well.

It’s pertinent to mention here that: as part of the Medicare Hospital Outpatient Prospective Payment System proposed rule for the year 2022. The Centers for Medicare & Medicaid Services seeks to impose penalties on the hospitals that don’t fulfil the price transparency requirements.

According to the new rule, the hospitals are bound to provide personalized information about consumers’ copays and out-of-pocket costs via an online, self-service tool. It has been predicted that the implementation of this rule will help in setting an initial set of 500 “shoppable services”. That will be available for healthcare consumers in 2023.

In addition to this, insurance companies will also be bound to publish the underlying negotiated rates paid to healthcare providers, historical information on charges, payments to out-of-network providers, negotiated rates and historical prices for covered prescription drugs. These details will be provided in machine-readable form. That will pave the way to enable data analysis and result in improved consumer shopping behaviour.

Now, health insurance agencies have the time till July 1, 2022, to publish these files, according to new guidance issued by the US federal authorities. The primary objective of making this information easily accessible is to encourage the patients to shop around for affordable healthcare providers and medical services as well. In this way, patients will become better able to make informed decisions. Whether or not they can afford the treatment from a particular healthcare practice.

Key Provisions

The key provisions of the proposed rule are:

Improving Patient Experience: The CMS intends to make significant changes in the Radiation Oncology (RO) Model. Which aims to alleviate the sufferings of cancer patients by ensuring standard medical aid. It will enable the patients to get radiotherapy and advance toward a streamlined and unsurprising payment system.

Access to Emergency Care in Rural Areas: In order to improve the quality of the healthcare services in the rural communities, suffering acute health crises. Such as; shorter life expectancy and lack of access to professional healthcare practitioners. Congress enacted Section 125 of the Consolidated Appropriations Act of 2021 (CAA). Which establishes a new provider type for Rural Emergency Hospitals (REHs), that will be responsible to deliver emergency medical care services.

Health Equity: In order, to ensure health equity, CMS is seeking precise and actionable reporting on healthcare disparities. Which aims to provide care services without the social risk factors, race and ethnicity.

The Impact

It’s worth mentioning here that the implementation of hospital transparency rules hasn’t necessarily been smooth. According to the recent survey report, below 6% of hospitals manage to comply with the rules. Rest failed to fulfil the requirements regarding negotiated prices and didn’t publish the full list of discounted cash prices.

On the other hand, patients want more transparency in the prices. According to a survey report, approximately 83% of patients want complete insights into their financial responsibilities before receiving treatments. Respondents who had used an insurer-provided price transparency tool show satisfaction. As they become able to make better decisions after understanding their healthcare coverage and benefits.

Moreover, the survey report also makes some shocking revelations as; 53% of healthcare consumers said that they didn’t avail the medical services. Because they weren’t sure about how much the particular procedures would cost them.

Just think for a while! how it can be frustrating for medical practitioners to lose patients just because of the non-transparency in pricing. It not only negatively impacts the reputation of the providers in the highly competitive healthcare industry. But it also affects the healthcare revenue cycle management. Because losing the healthcare consumers simply means you are losing more opportunities for revenue generation.

So, in order to keep pace with the ever-evolving healthcare industry, physicians should make changes in their medical billing systems according to the newly proposed rules. In this way, they can save their healthcare practices from legal risks i.e federal penalties, and financial loss as well.

Do you want to know more about the latest healthcare guidelines, issued by the concerned authorities? Then don’t go anywhere. Keep visiting Medical Billing Benefits to stay updated about all the latest happenings in the medical industry. It’s an insightful and more authentic healthcare newswire that contains reliable information. Subscribe to our newsfeed for an enhanced experience.

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