'Revenue cycle is a team sport' — 3 plays to get on the winning side of CMS' price transparency rule


In December 2017, a survey of more than 500 likely voters revealed patients' desire to better understand their healthcare costs ahead of time. The Foundation of Government Accountability found that 82 percent of respondents — regardless of political affiliation, age or gender — wanted to know the cost of nonemergency procedures in advance.

The federal government is taking action. On June 24, President Donald Trump signed an executive order directing hospitals and insurance companies to disclose negotiated rates and inform patients of their financial responsibility before procedures. Weeks later, CMS released three proposed rules, including one that would build on existing price transparency requirements. 

CMS' final rule on price transparency is expected to come out in November, but healthcare organizations can begin preparing now. During an Oct. 7 webinar sponsored by Ensemble Health Partners and hosted by Becker's Hospital Review, Julie Roberts, Ensemble's Vice President of Revenue Integrity, and Emily Jones, Senior Vice President of Patient Access, discussed what the proposal entails and how organizations can get ahead of it.

The push for price transparency

Effective Jan. 1, CMS began requiring all hospitals to disclose standard charges online in an easily accessible machine-readable file. In late July, CMS built on that guidance in its proposed rule for 2020. The latest proposal would require hospitals to publish payer-specific negotiated rates for at least 300 "shoppable" services, including 70 defined by CMS. Hospitals would select the other 230 procedures based on their unique circumstances and utilization.

Critical access hospitals, inpatient psychiatric hospitals and sole community hospitals are among those subject to the proposed requirements; ASCs and other nonhospital sites of care are not. Notably, the regulations extend to certain practitioners.

"It also would include estimation for [employed] physicians and providers that practice within those [included] sites," Ms. Jones said. "As you think of your ability to provide cost estimates, [if] your employed providers are billed out of a separate system from your facility system, those are things you should really be thinking through now."

While meeting those requirements will take careful planning, the stakes are high: Organizations that fail to publish charges in a searchable and consumer-friendly manner could be fined up to $300 a day per noncompliant facility, up to a maximum of $109,500 annually per hospital.

"If you're a 15-facility entity, you could be impacted by over $1 million in penalty costs," Ms. Roberts said. "Those costs need to go back into healthcare — to providing excellent service for our patients, new CT machines, a new X-ray scanner. Hospitals can't afford noncompliance."

To help hospitals avoid costly noncompliance, Ms. Roberts and Ms. Jones shared three ways to prepare for price transparency requirements:

1. Meet inclusion requirements. Hospitals will publish prices for the 70 services defined by CMS, as well as 230 additional services, which should be selected based on the individual facility's' utilization report, Ms. Roberts said. If a hospital doesn't offer one of the 70 services put forth by CMS, that service should still be listed, but with "Not Applicable" written in the charge section and an additional service tacked on to the 230 individually selected.

However, the minimum requirement of 300 services shouldn't stop organizations from including others that are relevant to patients, Ms. Roberts said. She anticipates CMS will increase the minimum down the road.

2. Consider the patient mindset. To ensure they present charge information in an easy-to-understand manner, some organizations are holding town halls or patient focus groups to shape their decisions around price displays.

Providers can also consider having a dedicated phone line for charge questions, an online FAQ page explaining charges in plain language, or video tutorials showing where to find pricing information on the website, Ms. Jones said. Real-time chat or text support can help patients navigate to that information in as few clicks as possible.

"As you are thinking through how you'll make this work for your organization, [think about] how you set it up visually so the patient knows immediately where to go and how [you can ensure] this information is easily accessible," Ms. Jones said.

3. Maintain internal communication. While communication with patients is central to price transparency efforts, internal communication can't go by the wayside. Staff in patient-facing roles, such as customer service, should be informed of pertinent information related to price transparency efforts. Additionally, it's important for organizations to consult with their compliance and legal departments — for instance, in situations where it's unclear what kind of disclosure a payer contract allows.

Assembling a cross-functional team dedicated to price transparency will help organizations remain in compliance with CMS' regulations. These councils should include more than just finance, contract management and revenue cycle teams — consider including the marketing, IT and EMR teams to find the most robust price transparency solution.

"Don't put yourself in a box by not inviting a champion from those teams to the table," Ms. Roberts said. "Revenue cycle is a team sport. Open yourself up to those perspectives to provide your patient with the best options."

Click here to listen to the webinar.

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