The Centers for Medicare & Medicaid Services (CMS) issued a Price Transparency Mandate, which requires six thousand hospitals in the US to publish their standard charges in a machine-readable format and a consumer-friendly manner on their websites from January 1, 2021. Starting Jan 1, 2022, the non-compliant hospitals will have to pay $300 per day upto 30 beds, and beds above 30 will pay $10/bed/day not exceeding $5500 per day. This requirement is the first step to taking complex healthcare pricing information and making it transparent.
According to CMS, the machine-readable file should include the following:
1) Comprehensive file with all items, services, and service packages which include:
- Gross charges
- Discounted cash prices
- Payer-specific negotiated charges
- De-identified minimum negotiated charges
- De-identified maximum negotiated charges
2)A consumer-friendly display that includes the following standard charges for at least 300 ‘shoppable’ services:
- Discounted cash prices (use gross charges if cash prices are not available)
- Payer-specific negotiated charges,
- De-identified minimum negotiated charges
- De-identified maximum negotiated charges
OR
Hospitals can use a patient estimator tool instead of ‘shoppable’ services.
Beginning January 1, 2021, the CMS started to monitor and enforce these price transparency requirements. For hospitals that do not comply, CMS may issue a warning notice, request a corrective action plan, impose a civil monetary penalty and publicize the penalty on a CMS website.
Recently two hospitals in Georgia, Northside Hospital Atlanta were penalized $883,180 and Northside Hospital Cherokee $214,320 by the CMS for non-compliance.
| Hospital Name | Penalty Amount | Effective Date |
| Northside Hospital Cherokee | $214,320.00 | 2021-09-09 |
| Northside Hospital Atlanta | $883,180.00 | 2021-09-02 |
We have analyzed more than 5000 hospital data across the United States to see if they are compliant with CMS requirements and simplified the data into a user-friendly format so that anyone can easily understand. We want to help hospitals that are non-compliant to become compliant using our price transparency engine, Zeatool. Our goal is to help hospitals take this big pricing data, navigate new ways to cut waste, increase revenue, and bring the antiquated healthcare system into the e-commerce age.
We analyzed 70 hospitals in the Other Region, found 9(13%) compliant, and 61(87%) are non-compliant with CMS requirements.
As of August 04, 2022, the non-compliant hospitals will face a cumulative penalty of $22,063,300.
American Samoa:
We analyzed 1 hospital in American Samoa, and found 0(0%) hospitals compliant, and 1(100%) hospitals are non-compliant with CMS price transparency requirements.
The one non-compliant hospital will face a total penalty of $322,500.
District of Columbia:
We analyzed 9 hospitals in the District of Columbia, found 2(22%) hospitals compliant, and 7(78%) hospitals are non-compliant with CMS price transparency requirements.
The 7 non-compliant hospitals will face a total penalty of $4,981,550.
Guam:
We analyzed 2 hospitals in Guam, found 0(0%) hospitals compliant, and 2(100%) hospitals are non-compliant with CMS price transparency requirements.
The 2 non-compliant hospitals will face a total penalty of $552,550.
Puerto Rico:
We analyzed 56 hospitals in Puerto Rico, found 7(13%) hospitals compliant, and 49(87%) hospitals are non-compliant with CMS price transparency requirements.
The 49 non-compliant hospitals will face a total penalty of $15,811,100.
Virgin Island:
We analyzed 56 hospitals in Puerto Rico, found 7(13%) hospitals compliant, and 49(87%) hospitals are non-compliant with CMS price transparency requirements.
The 49 non-compliant hospitals will face a total penalty of $15,811,100.
Disclaimer and Methods:
ZeaMed or its affiliate parties have collected the machine-readable files and data from hospital websites to see if the hospitals are compliant with CMS Price Transparency Requirements. The data is extracted from standard charges for items, services, service packages, and shoppable services. As per CMS, the mandatory data fields to be present in the file are tests/procedure codes, tests/procedure description, Gross prices, Cash Prices, negotiated insurance prices, de-identified minimum and de-identified maximum prices with IP, OP differentiation.
There could be some errors while extracting, analyzing, and updating the data. Providers are defining their own column/field names. MR files were available in the following formats CSV, EXCEL, JSON, XML, PDF, DOCX, HTML,Text. MR files had only billing IDs, and when they gave the identifiers, they did not make code type mapping like CPT, MS-DRG, APR-DRG, APC, HCPCS, NDC, Internal Codes. Most of the providers have not mentioned if the price includes all services.
Whatever the hospital websites have reported, that data is displayed here. ZeaTool helps the consumers, hospitals, and healthcare stakeholders understand what is in the machine-readable files. The data could also be from old files because some hospitals have not removed the old files from their websites. The data may not be available because some hospitals’ websites are not friendly and could not find the machine-readable files. In the case of a few providers, the file name was given under the health system name, making it complicated to identify the actual provider to which it belongs. Most providers use their internal names to identify the services, and it is different across the providers. Since some of the providers have not given unique codes, it is challenging to identify the services.
The patient estimator tools or costs provided via these tools are only estimates as per many hospital websites.
The information provided is from the hospital websites only; the users can decide if hospitals are compliant or not.
If any hospital has questions about their data and compliance, they can reach out to us and suggest any corrections to the data. We will make corrections to the data after verifying their data.
We are not responsible for the correctness of data, and it is for the user to check with the hospitals for the latest information. Also, the hospitals may have updated their data which may not reflect on this website. We are not responsible for any suits filed by anyone against the hospitals, and also, we do not take any responsibility for the information provided by the hospital. We are not responsible for any data discrepancies in visiting the website and checking the data’s compliance. The user of the information is responsible for verifying with the concerned hospitals.
We considered hospital to be compliant when the hospital gave the Machine-readable file that contains all items, services, service bundles that include gross, cash price, de-identified minimum price, de-identified maximum price, and insurance negotiated prices plus the 300 shoppable services that have discounted cash price (can give gross prices if cash payment is not available), de-identified minimum price, de-identified maximum price, and insurance negotiated price in a machine-readable format or a patient estimator tool on the hospital website. Since many providers have not given separate outpatient and inpatient prices, we have considered them applicable to both inpatient and outpatient patients except for MS-DRGs and APR-DRGs. The data can still show errors about the inpatient and outpatient services which we are not responsible for. We believe human errors and technological errors could also play a role in data discrepancies.
ZeaMed and Affiliate members, websites, apps, and other technologies and people are not responsible for data errors”.
References:
CMS