Centers for Medicare & Medicaid Services (CMS) enforcement of new price transparency rules began in January, and ClaraPrice, which provides consulting services to hospital IT, revenue cycle, and compliance teams, is looking to help providers stay ahead of the curve on making the necessary adjustments.
Specifically, CMS is standardizing the machine-readable file (MRF). Hospitals must now display their standard charge information in a CMS template layout, following data specifications and a data dictionary.
Hospitals also must now place a “footer” at the bottom of their homepage. This footer must link to the webpage, which includes the MRF. It must include a .txt file with the following:
Beginning July 1, 2024, each hospital must affirm that, to the best of its knowledge and belief, it has included all applicable standard charge information, and that the information encoded is true, accurate, and complete, as of the date specified.
Estimated Allowed Amount
A new data element, the estimated allowed amount, must be included in the MRF by Jan. 1, 2025. CMS also requires the listing of the historical allowed amount, an average reimbursement in dollars received from the payer in the past for an item or service. This data element will reflect the estimated dollar value when a standard charge is based on an algorithm or percentage. The estimated allowed amount supplements and does not replace the payer-specific negotiated charges for all items and services.
In addition to the changes above, CMS has modified requirements to improve enforcement capabilities and increase transparency. Enforcement changes include the following:
Is your hospital compliant with the 2024 Price Transparency requirements? If you need help, please contact ClaraPrice for a free price transparency evaluation.
Jory Hatton is the CEO of ClaraPrice, a healthcare IT corporation that specializes in the Medicare hospital price transparency rule and the No Surprises Act (NSA) compliance solutions. Jory has an academic background in computer science and enterprise software design, and a professional background in executive leadership ensuring client success and the innovative development of large-scale healthcare technology solutions.
jory@claraprice.com
UnitedHealthcare (UHC) Medicare Advantage will begin reinforcing denialsbased on its interpretation of the International Classification of Disease, 10 thEdition, Clinical Modification (ICD-10-CM) Excludes 1.(https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/rpub/UHC-MEDADV-RPUB-JAN-2026.pdf) As
Healthcare has been transitioning toward a more digital, interconnected ecosystem for many years, but the pace and magnitude of current changes represent a fundamental shift.
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