Healthcare Consulting News

Executive Order on Price Transparency

info@ghsri.com (GHS INC) — Fri, 28 Feb 2025 21:29:12 GMT

The Need for Comprehensive Pricing Content Regulation

In a decisive move to enhance healthcare price transparency, this week the President directed the Department of Health and Human Services (HHS), the Department of Labor, and the Department of Treasury to "rapidly implement and enforce" regulations. This directive underscores the urgency of providing patients with clear and accessible pricing information to make informed healthcare decisions. While the Centers for Medicare & Medicaid Services (CMS) has established guidelines on data format and structure, there remains a critical gap: regulating the actual content of pricing data.

The Challenge of Pricing Transparency in Healthcare

To comply with the Price Transparency rule, providers and payers are required to publish their standard charges which are defined as hospital charges and payer contractual rates. These standard charges (pricing) may vary significantly based on the type of service and the complexity of care provided to each patient.

For outpatient services (e.g., Imaging services and Laboratory tests), typically defined by Healthcare Common Procedure Coding System (HCPCS) codes, pricing is relatively straightforward. However, for more complex services, such as inpatient Diagnosis-Related Groups (DRGs) and outpatient Surgical Procedures, pricing is less predictable. The final cost of these services depends on various factors, including patient-specific needs and payer contractual terms. Additionally, high-cost items such as implantable supplies and biologicals are often reimbursed separately under carve-out payment terms, which are frequently omitted from published rates. Since patients undergoing the same procedure may require different implants or biologicals, their final costs can vary widely. As a result, published rates that exclude carve-out payments provide an incomplete picture of expected expenses.

The Need for Comprehensive Pricing Content Regulation

To address these gaps, HHS and the Departments of Labor and Treasury should prioritize improving guidance for the content of Machine-Readable Files (MRFs) published by providers and payers. The goal is to ensure that pricing information reflects both contracted rates and historical payment trends, offering a more accurate estimate of costs for consumers.

Proposed Changes for More Meaningful Transparency

1. Single HCPCS Code Services:

- Standard charges should be reported as the hospital's published charges in the charge description master (CDM).

- Each payer plan’s contractual rate should be clearly documented to ensure price comparisons.

2. Multiple-Charge Services (e.g., Inpatient DRGs, Outpatient Surgical Procedures):

- Contracted Rates by Payer Plan: Providers should report the negotiated rates for each payer plan.

- Estimated Rates Based on Historical Data: To account for carve-out payments, historical patient claims data from the most current past 12 months can be used to calculate median standard charges. This approach ensures that estimated rates better reflect the actual costs patients may incur.

3. Modifier Reporting:

- Report modifiers only when they impact final rates, as many modifiers do not alter the actual payment amount.

Moving Toward a Transparent Future

The administration’s directive is a necessary step toward true price transparency, but meaningful reform requires clear and consistent pricing content regulation. By refining MRF content standards and ensuring the inclusion of comprehensive pricing data, regulators can help providers and payers present information in a way that truly benefits patients. Enhanced transparency will empower consumers to make informed decisions, foster competition, and drive accountability within the healthcare industry.

Free 2024 MRF Assessment

info@ghsri.com (GHS INC) — Mon, 10 Jun 2024 18:18:00 GMT

Free 2024 MRF Assessment

As we are near CMS’ July 1, 2024 mandate for hospitals to publish the updated Machine Readable File, Good Healthcare Solutions is available to provide a free assessment of your final MRF. Additionally, we are able to look at both csv and JSON files and can assist in converting them to a CMS compliant format if needed. Please feel free to contact us at info@ghsri.com for any 2024 MRF related questions.

Navigating CMS 2024 MRF Rule Updates

info@ghsri.com (GHS INC) — Fri, 22 Mar 2024 17:51:39 GMT

Navigating CMS 2024 Machine Readable File Rule Updates

The Centers for Medicare & Medicaid Services (CMS) has recently introduced additional data requirements for the Machine-Readable File (MRF), marking a significant step towards greater transparency and accountability within the industry.

One of the key mandates put forth by CMS is the inclusion of contractual types in the 2024 MRF by July 1, 2024. This requirement underscores the importance of understanding the intricacies of hospital contracts, which play a pivotal role in shaping financial outcomes. Moreover, CMS announced during their January 2024 MRF webcast that they have an audit tool in development and is slated for release in the Spring. This tool is poised to enhance the accuracy and reliability of published MRF data, ensuring compliance with regulatory standards.

Another notable addition to the MRF requirements is the necessity for the document to be signed off by the hospital's executive. This endorsement signifies a commitment to accountability and oversight at the highest level, instilling confidence in the integrity of the data reported.

Historically, managed care rate analysis relied on percentile measurements derived from market basket data. Through the MRFs, Hospitals now publish detailed rate information, facilitating a more nuanced assessment of financial performance. However, to harness the full potential of this wealth of data, it is imperative to establish robust data analysis criteria. Without standardized methodologies, meaningful comparisons and actionable insights may prove elusive.

Recognizing this need, our team has leveraged extensive industry knowledge to develop cutting-edge software. This software harnesses advanced data algorithms to generate actionable insights for strategic planning, contract negotiation, and revenue optimization. By automating the analysis process, our solution empowers healthcare providers to make informed decisions based on reliable, real-time data.

CMS's new MRF requirements represent a significant stride towards enhancing transparency and accountability within the healthcare sector. By mandating the inclusion of contractual types and instituting rigorous data validation measures, CMS is paving the way for more accurate financial reporting. With the right tools and methodologies in place, healthcare providers can unlock actionable insights to drive sustainable growth and improved patient outcomes.

GHS MRF Tool is 2024 Compliant

info@ghsri.com (GHS INC) — Fri, 06 Oct 2023 20:33:39 GMT

GHS MRF Software is now 2024 compliant

GHS has updated the programming logic in our Machine-Readable File (MRF) automation tool to assist clients to effectively and efficiently generating a compliant and user friendly file based on CMS recently published 2024 HOPPS rule. Some of the proposed data fields, such as: contracting method and rate calculation based percentage of billed charges can be populated into the MRF format without additional client’s involvement. The historical data and formula would be stored for ease of annual MRF update.

Solutions to Price Transparency Compliance

info@ghsri.com (GHS INC) — Tue, 14 Jun 2022 21:11:22 GMT

Solutions to Price Transparency Compliance

With the new CMS fines for hospitals in non-compliance with the Price Transparency rule, administrators may feel like they need to play catch up to avoid being targeted by CMS. The tasks of trying to convert thousands of individual charges and hundreds of contractual variations to price transparency shoppable services and machine-readable file can be overwhelming. But based on our years of experience in charge capture, coding and price transparency compliance work, we highlighted five steps all hospitals can take to start their journey on the road to compliance using our standardized price machine-readable template:

1. Primary Service Codes : hospitals can begin by organizing their services based on primary service codes. A few examples would be individual HCPCS codes, non-HCPCS coded services (e.g., R&B), and multiple charges grouped by Primary service identifier (e.g., DRGs. ASCs).

2. Payer Plans : the next step is to organize payer plans based on contractual terms and populate charges per price transparency rule for each primary service and each payer plan.

3. Self-pay Discount Rates : each item and service should be matched to their self-pay discount rates.

4. Min and Max Charges : identify the low and high charges for each primary service code.

5. Compile : hospitals should populate the organized data from steps 1 through 4 into a file that can be easily accessed by patients and maintained internally.

Hospitals should also organize a core team to maintain the price transparency machine readable file and 300 shoppable services with a proper audit trail and guiding principles.

Following this roadmap allowed us to improve our price transparency compliance turnaround time for clients from approximately 4 months in 2020 to 2 months in 2021.

JAMA Study of Price Transparency Compliance

info@ghsri.com (GHS INC) — Tue, 14 Jun 2022 02:40:32 GMT

JAMA Study of Price Transparency Compliance

In the June 7, 2022 JAMA publication, a study found that compliance with the Federal Price Transparency rule was extremely low across all US hospitals. The study looked at available data between July 1 to September 30, 2021 for 5,239 hospitals and found only 5.7% of hospitals had both machine-readable files and shoppable services posted. The percentage of hospitals that had a machine-readable file but no shoppable services was 13.9% and the percentage with shoppable services but no machine-readable file was 29.4%. About half, 50.9%, of hospitals had neither a machine-readable file nor shoppable services.

This study was completed with 2021 data so the numbers may be different in 2022, especially in light of the CMS changes in fines for non-compliant hospitals post 1/2/2022 and fines that were just given to two Georgia hospitals. We look forward to seeing future studies like this as they will gauge whether the CMS penalties are increasing the compliance rate among hospitals.

Price Transparency Fines Become Reality

info@ghsri.com (GHS INC) — Sun, 12 Jun 2022 03:37:05 GMT

Price Transparency Fines Become Reality

CMS has issued the first fines for violating the hospital price transparency rule. The recipients of these historic fines are Northside Hospital Atlanta in Atlanta, GA and Northside Hospital Cherokee in Canton, GA. These fines came after CMS issued both Requests for Corrective Action Plan (CAP) and warning notices to the hospitals in 2021. It was the lack of a CAP submission from the hospitals that most likely triggered the monetary penalties of $833,180 and $214,320 for Atlanta and Cherokee, respectively. CMS may also issue additional fines if the price transparency rule violation is not corrected.

This seven figure fine shows CMS is taking price transparency noncompliance seriously and will go after the hospitals’ bottom lines if necessary. While a million dollars is relatively small compared to the billion dollar revenue of most large hospitals, the fine is also several times the expense required to produce the price transparency files and data. These fines also create legal expenses for hospitals that choose to fight them in court and bad publicity as most consumers agree with more price transparency in healthcare.

For hospitals who have not committed to price transparency compliance, the risk of monetary penalties is no longer theoretical. CMS has fired its first warning shot with these fines against Northside Atlanta and Northside Cherokee. But it’s also not too late as, with proper guidance, a hospital can quickly and efficiently create the necessary files so to avoid the hassle of dealing with CMS fines and court proceedings.

https://www.washingtonpost.com/politics/2022/06/09/two-hospitals-are-being-fined-disobeying-price-transparency-rules/

Good Faith Estimate – What to do after Jan 1, 2022

Sat, 01 Jan 2022 19:00:04 GMT

Good Faith Estimate - What to do after Jan 1, 2022

Providers should view the uninsured GFE requirement as the first step in new federal regulations on healthcare providers. Even once a provider is compliant with the GFE requirement, there will be continual work required to make sure their compliance does not lapse. Two things providers can do is to monitor their GFE workflow and stay apprised of Federal regulations and CMS updates that may affect their billing practices.

Once a provider has identified their self-pay population, the prices for all identified services, and integrated the workflow into their daily operations, they should think about monitoring the GFE workflow efficiency and GFE accuracy. To identify and track potential issues, providers should look at their self-pay volumes, services (HCPCS codes or MS-DRGs) and service locations to make sure they are consistent with prior data. Providers can also compile patient feedback as an important data source. Lastly, providers can monitor and analyze the difference in charges between the GFE and captured charges, which should have a variance of $400 or less . These monitoring activities will tell providers the frequency of charge disputes and if any additional training is needed for the staff.

To maintain compliance with GFE requirements, providers should be able to update the GFE at time of service. They should also identify and organize their co-provider list and coordinate with co-providers on obtaining their GFE. Lastly, they should monitor CMS regs to stay up to date on any changes to these requirements.

Preparing for the Good Faith Estimate

Fri, 31 Dec 2021 18:59:53 GMT

Preparing for the Good Faith Estimate

To ring in the New Year, here is a quick summary of how healthcare providers like hospitals and physician practices can develop the required workflow and resource utilization to meet the 2022 Good Faith Estimate requirements by following a few key steps.

Providers should identify the self-pay population and services first as the rule currently only applies to uninsured patients. This can be easily performed by filtering 2021 self-pay data for the following: non-emergency self-pay patients, organize each encounter by primary HCPCS code or MS-DRG, volume based on primary HCPCS code or MS-DRG, and identify service location and involved scheduling department(s). Providers should also engage the operations leadership team by providing background information and a GFE project plan.

Once the population has been identified, then the Good Faith Estimate can be established for each self-pay service. Providers should leverage their 300 Shoppable Services from the Price Transparency regulation to help develop the GFE for self-pay patients. They can also utilize a price estimator tool to develop the GFE for all identified services. After determining the initial prices for the GFE, providers should review the gross charges and/or discounted charges for appropriateness based on historical charge data aggregation.

To implement an updated workflow, providers should develop a straw-model of future state GFE workflow and workbench. They will need to incorporate a standardize notification letter for GFE patients and the method of transmission, which can be either a hardcopy or a digital format. And, of course, all this data and new workflow must be incorporated into a staff training plan with tip sheets.

Right Size Patient Billable Charges to Streamline Revenue Cycle Outcomes

Wed, 22 Jul 2020 20:52:22 GMT

Right Size Patient Billable Charges to Streamline Revenue Cycle Outcomes

Despite the significant financial impact of the Covid-19 pandemic, US healthcare providers and hospital organizations continue to implement strategic and tactical measures in order to manage financial challenges while ensuring optimal patient care and health promoting missions. Many innovative operational and service modifications have been adapted by the industry since March 2020. However, there are other fundamental changes that can improve the Revenue Cycle process and outcomes should be considered by providers and hospitals.

Efforts to ensure accurate and timely charge capture and subsequent claims scrubbing (e.g., charge review) can be labor intensive with less than optimal returns. Reasons hindering this costly process are due, in part, to the complexity of charge created by providers and hospitals and ever growing third party insurance (governmental and commercial) billing and coding requirements. Providers and hospitals can minimize their exposure by streamlining the charge structure and smart claims generation process thereby lessening chances for third party rejection and denial of claims.

For years, the exploration of revenue opportunities was tied to expanding billable services listed in the Charge Description Master (CDM) and improving coding qualities. As a result, there are many low impact charges in each CDM that are creating process inefficiencies and delays in payments. Below are just a few primary examples:

Increased the need to develop Revenue Integrity SMRs to manage CDM and charge capture accuracy
Increased frequency of claim edits that are costing hospital FTEs and delays in payments
Provided additional opportunities for third party payers to reject or deny claims when reporting low impact patient charges
Created challenges for hospitals to efficiently use claims data for meaningful trend analysis, quality control and process improvement activities

Streamlining CDM and charge structure will enable hospitals to achieve the following improvements:

Improved AR when there is a reduction in reporting of low impact patient charges (e.g. Streamlining Pharmacy charges that decreased outpatient denials by 35% with no impact on payments)
Enabled resources to focus charge capture accuracy and timeliness on meaningful patient billable charges (Modifying patient billable charges can improve daily claim processing and routing CDM maintenance up to 40%)
Improved efficiencies of data analytics once the low impact charges were removed from charging
Will enable the ability to publish meaningful charges in light of January 1, 2021 Price Transparency requirements
Improves the ability to adapt to various future Revenue Cycle related automation measures

Making major CDM and charge structure changes will not be a small task as this initiative will impact an organization's operations, finance, and managed care contract negotiations. It will require a coordinated effort by several departments and use data analytics to support the final decisions. Once the decisions are finalized, the implementation can be carried out in a staggered fashion to improve success rate. But given that the benefits outweigh the efforts, it is a good idea for healthcare organizations to start streamlining their CDM and charge structure to reap the rewards.

Healthcare Consulting News

Executive Order on Price Transparency

The Need for Comprehensive Pricing Content Regulation

Free 2024 MRF Assessment

Free 2024 MRF Assessment

Navigating CMS 2024 MRF Rule Updates

Navigating CMS 2024 Machine Readable File Rule Updates

GHS MRF Tool is 2024 Compliant

GHS MRF Software is now 2024 compliant

Solutions to Price Transparency Compliance

Solutions to Price Transparency Compliance

JAMA Study of Price Transparency Compliance

JAMA Study of Price Transparency Compliance

Price Transparency Fines Become Reality

Price Transparency Fines Become Reality

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Good Faith Estimate – What to do after Jan 1, 2022

Good Faith Estimate - What to do after Jan 1, 2022

Preparing for the Good Faith Estimate

Preparing for the Good Faith Estimate

Right Size Patient Billable Charges to Streamline Revenue Cycle Outcomes

Right Size Patient Billable Charges to Streamline Revenue Cycle Outcomes