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On November 15^th, the Trump administration announced historic price transparency requirements to increase competition and lower healthcare costs for all Americans.  In response to President Trump’s Executive Order signed in July 2019, the Department of Health and Human Services took action to advance the Trump administration’s commitment to increasing price transparency in the health care industry and promote public access to hospital standard charges.[1] The announcement focuses on a final rule and a proposed rule.

The final rule requires hospitals to display their secret, negotiated rates to patients starting in January 2021. Hospitals will be required to make public all “standard charges” online in a single data file that can be read by other computers. “Standard charges” include gross charges, payer-specific negotiated charges, the amount the hospital is willing to accept in cash from a patient, and minimum and maximum negotiated charges.[2] Other items and services that must be disclosed include supplies, facility fees, and professional charges for employed physicians and other practitioners. This information and format will be most useful for employers, providers, and tool developers when designing consumer-friendly price transparency tools in the future.

Hospitals also need to make public the standard charges for at least 300 common “shoppable services” and describe this information in plain language. “Shoppable services” include x-rays, outpatient visits, imaging and laboratory tests.[3] This information must be easily accessible, in a searchable format, and be updated annually.[4] The goal of this requirement is to ensure that healthcare consumers can compare services between different hospitals and mitigate cost surprises. [5] Of the 300 shoppable services, the rule specifies 70 services that must be included (see table below for the required 70 services). The other 230 services will be chosen by the hospital. In order to ensure compliance with the final rule, the Centers of Medicare & Medicaid Services (“CMS”) has the authority to impose fines on the hospital up to $300 per day and $109,500 for the entire year. Some critics of the final rule argue this monetary penalty will be an insufficient enforcement tool given the relatively insignificant amount a hospital will be forced to pay.[6] Other enforcement tools include monitoring hospital compliance, evaluating complaints made by individuals and entities sent to CMS, and auditing hospital websites.[7]

The second rule discussed in the announcement is a proposal that would require insurance companies to show patients their expected out-of-pocket costs instantly through an online tool or in paper form, if requested. If finalized, the Transparency in Coverage proposed rule would also require health insurance companies and group health plans that cover employees to disclose on a public website their negotiated rates for in-network providers and allowed amounts for out-of-network providers.[8] Insurers would need to explain how much a service would cost, the amount an insurance plan would pay, and how much the consumer would owe before the service is rendered.[9] This requirement is intended to promote informed and price-conscious decision making and drive competition in the healthcare industry.[10] The proposed rule is subject to a 60-day public comment period. Comments are due by 5 p.m. on January 14, 2020 and may be submitted online at https://www.regulations.gov/ or by mail to the Centers for Medicare & Medicaid Services.

Summary:

These rules are a historic step toward price transparency across the health care industry and are in furtherance of the Trump administration’s goal of empowering healthcare consumers. The finalized rule and the proposed rule strive to make pricing information more available to healthcare consumers so they can make informed health care decisions. Through price transparency, consumers should expect to see a reduction in healthcare costs in the future. In order to provide hospitals enough time for compliance with the new requirements, the effective date of the finalized rule is January 1, 2021. The comment period for the proposed rule is open until January 14, 2020.

Please contact a BMD healthcare attorney if you have any questions on the new price transparency rule or would like to submit written comments for the proposed rule, if you have any questions on how these rules may affect your practice, or if you have any other healthcare related questions in general. 

TABLE 3—FINAL LIST OF 70 CMS-SPECIFIED SHOPPABLE SERVICES Evaluation & Management Services [11]	2020 CPT/HCPCS Primary Code
Psychotherapy, 30 min	90832
Psychotherapy, 45 min	90834
Psychotherapy, 60 min	90837
Family psychotherapy, not including patient, 50 min	90846
Family psychotherapy, including patient, 50 min	90847
Group psychotherapy	90853
New patient office or other outpatient visit, typically 30 min	99203
New patient office of other outpatient visit, typically 45 min	99204
New patient office of other outpatient visit, typically 60 min	99205
Patient office consultation, typically 40 min	99243
Patient office consultation, typically 60 min	99244
Initial new patient preventive medicine evaluation (18-39 years)	99385
Initial new patient preventive medicine evaluation (40-64 years)	99386
Laboratory & Pathology Services	2020 CPT/HCPCS Primary Code
Basic metabolic panel	80048
Blood test, comprehensive group of blood chemicals	80053
Obstetric blood test panel	80055
Blood test, lipids (cholesterol and triglycerides)	80061
Kidney function panel test	80069
Liver function blood test panel	80076
Manual urinalysis test with examination using microscope	81000 or 81001
Automated urinalysis test	81002 or 81003
PSA (prostate specific antigen)	84153-84154
Blood test, thyroid stimulating hormone (TSH)	84443
Complete blood cell count, with differential white blood cells, automated	85025
Complete blood count, automated	85027
Blood test, clotting time	85610
Coagulation assessment blood test	85730
Radiology Services	2020 CPT/HCPCS Primary Code
CT scan, head or brain, without contrast	70450
MRI scan of brain before and after contrast	70553
X-Ray, lower back, minimum four views	72110
MRI scan of lower spinal canal	72148
CT scan, pelvis, with contrast	72193
MRI scan of leg joint	73721
CT scan of abdomen and pelvis with contrast	74177
Ultrasound of abdomen	76700
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus	76805
Ultrasound pelvis through vagina	76830
Mammography of one breast	77065
Mammography of both breasts	77066
Mammography, screening, bilateral	77067
Medicine and Surgery Services	2020 CPT/HCPCS/DRG Primary Code
Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities	216
Spinal fusion except cervical without major comorbid conditions or complications (MCC)	460
Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications (MCC).	470
Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC).	473
Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid conditions or complications (MCC)	743
Removal of 1 or more breast growth, open procedure	19120
Shaving of shoulder bone using an endoscope	29826
Removal of one knee cartilage using an endoscope	29881
Removal of tonsils and adenoid glands patient younger than age 12	42820
Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope	43235
Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope	43239
Diagnostic examination of large bowel using an endoscope	45378
Biopsy of large bowel using an endoscope	45380
Removal of polyps or growths of large bowel using an endoscope	45385
Ultrasound examination of lower large bowel using an endoscope	45391
Removal of gallbladder using an endoscope	47562
Repair of groin hernia patient age 5 years or older	49505
Biopsy of prostate gland	55700
Surgical removal of prostate and surrounding lymph nodes using an endoscope	55866
Routine obstetric care for vaginal delivery, including pre-and post-delivery care	59400
Routine obstetric care for cesarean delivery, including pre-and post-delivery care	59510
Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care	59610
Injection of substance into spinal canal of lower back or sacrum using imaging guidance	62322-62323
Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance	64483
Removal of recurring cataract in lens capsule using laser	66821
Removal of cataract with insertion of lens	66984
Electrocardiogram, routine, with interpretation and report	93000
Insertion of catheter into left heart for diagnosis	93452
Sleep study	95810
Physical therapy, therapeutic exercise	97110

 

[1] CMS-1717-F2

[2] U.S. Dept. of Health & Human Serv., Trump Administration Announces Historic Price Transparency Requirements to Increase Competition and Lower Healthcare Costs for All Americans (Nov. 15, 2019), https://www.hhs.gov/about/news/2019/11/15/trump-administration-announces-historic-price-transparency-and-lower-healthcare-costs-for-all-americans.html

[3] Id.

[4] Id.

[5] Id.

[6] Steven Porter, Enforcing Hospital Price Transparency: Is $300 max daily fine big enough? HealthLeaders (Nov. 15, 2019), https://www.healthleadersmedia.com/finance/enforcing-hospital-price-transparency-300-max-daily-fine-big-enough

[7] CY 2020 Hospital Outpatient Prospective Payment System (OPPS) Policy Changes: Hospital Price Transparency Requirements (CMS-1717-F2), Centers for Medicare & Medicaid Services (Nov. 15, 2019), https://www.cms.gov/newsroom/fact-sheets/cy-2020-hospital-outpatient-prospective-payment-system-opps-policy-changes-hospital-price

 [8] U.S. Dept. of Health & Human Serv., Trump Administration Announces Historic Price Transparency Requirements to Increase Competition and Lower Healthcare Costs for All Americans (Nov. 15, 2019), https://www.hhs.gov/about/news/2019/11/15/trump-administration-announces-historic-price-transparency-and-lower-healthcare-costs-for-all-americans.html

[9] Selena Simmons-Duffin, Trump Wants Insurers and Hospitals To Show Real Prices To Patients, NPR (Nov. 15, 2019), https://www.npr.org/sections/health-shots/2019/11/15/779707609/trump-wants-insurers-and-hospitals-to-show-real-prices-to-patients

[10] U.S. Dept. of Health & Human Serv., Trump Administration Announces Historic Price Transparency Requirements to Increase Competition and Lower Healthcare Costs for All Americans (Nov. 15, 2019), https://www.hhs.gov/about/news/2019/11/15/trump-administration-announces-historic-price-transparency-and-lower-healthcare-costs-for-all-americans.html

[11] CMS-1717-F2, https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf