How to increase price transparency while transforming the patient experience: 5 insights

Over the past year, CMS published its overall proposed then finalized rule for price transparency, and published the Inpatient Prospective Payment System proposed rule in September.

While hospital groups and state hospital associations petitioned the regulations in July and a federal appeals court began hearing oral arguments opposed to the new rules from the American Hospital Association and hospitals in October, many organizations are preparing as if the rule will be in full effect in 2021.

During an Oct. 27 webinar hosted by Becker's Hospital Review and sponsored by Ensemble, industry experts discussed how the price transparency regulations will impact the healthcare industry and how organizations can best prepare to meet compliance.

The presenters were:

  • Emily Jones, senior vice president of patient access at Ensemble
  • Stephen Forney, CFO at Covenant Health (Tewksbury, Mass.) 
  • Lena Tisten, senior director of revenue integrity at Ensemble

Five takeaways:

1. Organizations need a single machine-readable digital file that shows standard charges. From a patient's perspective, having access to a list of standard charges of items and services is vital and is one of the main components of the overall price transparency rule, Ms. Jones said. Five specific items that individuals can access under this machine-readable file are: gross charges, discounted cash prices, payer-specific negotiated charges, de-identified minimum negotiated charges and de-identified maximum negotiated charges.

2. New rules requires organizations to post 300 shoppable services. CMS has listed 70 specific services to fall under this category, which essentially covers services that can be scheduled in advance. Individual facilities can decide the additional 230 shoppable services they would like to include in their overall 300.

3. Price transparency rules may create potential new concerns for hospitals. By posting negotiated rates or other prices online, healthcare organizations will be putting a lot of information out in the public domain that historically has not been public, Mr. Forney said. Not just consumers will be interested in the data, but also employers, other health plans and competitors, too.

"This will open up a number of different dynamics potentially across the healthcare industry," Mr. Forney said. "While many are speculative, some examples include health plans possibly trying to use this information in negotiations, and I expect most CFOs or most employers are going to start being approached by consultants that will use this information to say, 'Hospital X is cheaper than hospital Y. You should try to direct your business to hospital X.'"

4. New transparency regulations introduce potential benefits to market rates. The new rule will allow organizations to better understand where they fit in the market relative to rates, Mr. Forney said, adding that it will allow payers to go directly to employers and show them exactly where they are positioned in the market and why they should partner with their organization for services.

5. Consider CPT and HCPCS codes when creating 300 shoppable services selection strategy. When picking out which 230 additional services to add under the 300 shoppable services, organizations should run utilization based on CPT and HCPCS codes to look at what the highest utilization of services has been over the course of time, Ms. Tisten said.

"We know that we had COVID-19 this year, and that we had a really high utilization of those services for that, but running utilizations from the beginning of the year for a six month period or an eight month period will help give you a good start with selecting those initial services," she said.

Click here to view a recording of the webinar presentation.

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