The globe is witnessing popularity in compliance programs in healthcare organizations. If you have been following us, you may have a clear idea of price transparency. Price transparency is the backbone of democratic healthcare. Therefore it is the need of the hour. In the current era of consumerism, consumers need to be fully aware of what they will pay for. Therefore the same goes for healthcare. The CMS (Centers for Medicare and Medicaid Services) focuses on transparent healthcare for all Americans. Patients must know beforehand the type, quality, and cost of services they are going to receive.

Several independent organizations, medical fraternity groups, and other healthcare stakeholders have pressed on the need for consumer independence in healthcare. American consumers have the right to know about the cost of healthcare services in advance like other consumer goods. Therefore, ZeaMed, with a mission to bring total transparency in healthcare, is moving forward to disrupt healthcare costs and democratize them. 

What is a price transparency compliance program in a healthcare organization?

A compliance program in healthcare is a broad concept that begins with price transparency. The CMS regulates all hospitals operating in the United States to publish the standard charges in a consumer-friendly format. The goal is to ensure every consumer or patient knows the cost of healthcare beforehand. Thus, it makes them aware of what services they are opting for, and it helps them arrange the finance or if they are paying from their pockets. In addition, if they are using insurance for the coverage of services, they at least know where their out-of-pocket costs are cheaper.

Health transparency would also mean transparency in quality and access to care. In addition, it demands rationalization of healthcare costs, quality, and availability of services across the United States and globally.

The CMS(Centre for Medicare and Medicaid Services), long before, had realized the need for a compliance program in healthcare. Therefore they mandated it in 2019. The CMS rule made it compulsory for all hospitals to

  • Display the cost of 300 shoppable services, which patients can schedule beforehand.
  • Provide comprehensive machine-readable files of negotiated chargemaster prices, including gross price, discounted cash prices, insurance- negotiated prices, de-identified minimum, and de-identified maximum prices.

The question arises whether all the US hospitals have complied with the CMS rule. Unfortunately, despite CMS reminders and all stakeholders’ outcry, most hospitals have failed to publish the transparency prices. ZeaMed has analyzed 5139 acute care hospitals’ websites and found that more than 75% of hospitals failed to publish transparent prices. ZeaMed’s analysis findings correlate with many studies published in 2021. Even the highly profitable health systems and hospitals have disappointed American consumers. 

Warnings and penalties for non-compliance

The CMS had issued warnings to non-compliance, giving a 90-day window for the hospitals to take corrective action. In addition, CMS has set a minimum civil monetary penalty of $300 per day for non-compliant hospitals.

With the non-response from the hospitals, the CMS has changed the fixed penalty to a sliding scale penalty format. As a result, since Jan 1, 2022, the fines for hospitals below 30 beds will be $300/day; from above 30 beds, the penalty will be $10/ bed/ day, not exceeding $5500 per day. So the total liability for non-compliance could be $2,007,500

What should actual compliance mean?

Complying with hospital price transparency includes five types of standard charges.

1. The gross charge 

2. The discounted cash price 

3. The payer-specific negotiated charge 

4. The de-identified minimum negotiated charge 

5. The de-identified maximum negotiated charge.

A consumer-friendly format includes the following standard charges for at least 300 ‘shoppable’ services: 

  • discounted cash prices (if cash prices are not provided, use gross amounts)
  • payer-specific negotiated charges,
  • de-identified minimum negotiated charges and 
  • de-identified maximum negotiated charges. 

What can hospitals do for price transparency?

CMS price transparency demands a set of activities from the hospitals.

  • The hospitals can also use a patient estimator tool to display the 300 shoppable services.
  • The hospitals should publish the standard charges for inpatient and outpatient items and services; charges for employed physicians and non-physician practitioners; charges for using the facility (e.g., facility fees); Standard charges for room and board, supplies, and procedures; and any other items and services for which the hospitals have established a standard charge.
  • The hospitals should include all required data elements: A description of each item or service; include any code used by the hospitals for accounting or billing for the item or service, including, but not limited to, the CPT code, the HCPCS code, the DRG, or another commonly used payer identifier.
  • The hospital should present data in a machine-readable format like CSV, XML, JSON, etc.
  • The Hospital Price Transparency Final Rule defines the machine-readable filene-readable file: <ein>_hospital-name_standardcharges.[json|xml|csv] 
  • Each hospital location operating under a single hospital license that has a different set of standard charges than the other location(s) operating under the same hospital license (or approval) must separately make public the standard charges applicable to that location (45 CFR 180.50(a)(2)).
  • The hospitals must post machine-readable files on a publicly available website. The pricing information must be easily accessible, free of charge, not require registration with a user account or password, and not request any personally identifying information (PII).
  • Hospitals should update the machine-readable file annually and indicate when the hospital has updated the recent file. In addition to this, the information must become easily accessible, be free of charge, not require registration or user account or password, and not request personally identifying information (PII).
  • The hospitals must post a consumer-friendly standard charge of at least 300 shoppable and related ancillary services. The CMS has prescribed seventy shoppable services and let hospitals choose 230 shoppable services. If a hospital can not provide 300 shoppable services, it must make public as many shoppable services as it provides. Suppose a hospital does not offer one or more CMS-specified shoppable services. In that case, they must either indicate “N/A” for the corresponding charge that the hospital does not provide the shoppable service. 

How is ZeaMed affecting price transparency 2022?

ZeaMedHealth is a global price transparency leader and wants to empower consumers, providers, the government, and other healthcare stakeholders by bringing total transparency. ZeaMed Health has built a suite of tools to help hospitals become compliant and a marketplace for consumers, employers, and other users to compare and purchase the services.

Zeatool is a price transparency engine that helps hospitals arrange their pricing data and publish machine-readable files and 300 shoppable services mandated by the CMS. In addition, Zeatool has a built-in semi-automated compliance engine where the tool will check if the hospital meets the CMS price transparency compliance. Zeatool also helps hospitals to create a patient estimator tool.

ZeaMed is a marketplace for consumers, employers, and other stakeholders to compare the providers’ cost and quality of services in a geographic location. Self-insured employers can also use the comparison tool to negotiate better prices with the providers and save out-of-pocket costs for their employees.

We at ZeaMed are offering the most standard rates for initiating hospital compliance. You need to reach us with the details, and we will provide you with quick solutions. 

We appreciate and honor hospitals with ZeaStar Certificates that comply with the CMS price transparency rule and go above and beyond to help their consumers. Our expert team can help hospitals become compliant and prevent them from facing huge penalties. 

How to make your hospital CMS compliant with ZeaMed?

We have noticed that some hospitals have difficulty meeting compliance due to a lack of resources. Some of the hospitals also have an incomplete understanding of the requirements. Since hospitals are struggling with taking care of Covid patients and retaining the workforce, ZeaMed can be a trustful partner at the moment. ZeaMed will help hospitals become compliant and repose faith in their consumers. 

The hospitals or health systems looking to become CMS compliant can reach out to us at info@zeamedhealth.com.

References:

https://www.cms.gov/newsroom/press-releases/cms-proposes-rule-increase-price-transparency-access-care-safety-health-equity

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