Pricing Transparency: Machine-Readable File

The Centers for Medicare & Medicaid Services (CMS) issued two rules effective January 1, 2021 that take historic steps to increase price transparency to empower patients and increase competition among all hospitals, group health plans and health insurance issuers in the individual and group markets. One of the rules is the Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) Price Transparency Requirements for Hospitals to make a machine-readable file containing a list of all standard charges for all items and services public.1

The Requirement

Per 45 CFR-PART 180, a hospital must make two items public1

  • Report of standard charges for an individual item or service (e.g., listed in the CDM) or package service (e.g., IP DRGs or OP surgical procedures in a machine-readable format)
  • Report of standard charges for 300 shoppable services*

Standard Changes Include the Following Elements1

  • Gross charges
  • Discounted cash price
  • Payer-specific negotiated charge: The charge that a hospital has negotiated with a third-party payer for an item or service (Each payer’s negotiation charge must be clearly associated with the name of the third-party payer’s name and plan)
  • De-identified minimum and maximum negotiated charges
  • New Procedure/Service Pricing
  • Supply Charge Determination
  • Drug Charge Determination
  • Time-based Charging
  • Bundled Charging

Footnotes:

1: Health and Human Solutions [Nov 7, 2019] [https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf.] (Jan 10, 2021).

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Published

July 28, 2022

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David Benn

Senior Managing Director

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