The caveat of payers' current posted prices

The CMS transparency in coverage rule took effect July 1, requiring payers nationwide to publish the cost of nearly every healthcare service they've negotiated with providers. But it will take time before any of that data is useful to patients, according to The Washington Post.

The rule requires payers to disclose in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for all covered items and services, and negotiated rates and historical net prices for covered prescription drugs administered by providers.

The data must be posted online in machine-readable files, with large files meant to be analyzed by third-party researchers. According to the Post, until tools are created to help patients search through that data, it isn't useful for understanding the cost of services.

Payers not in compliance with the new rule could face fines of up to $100 per day for each violation and for each individual affected by the violation.

An AHIP spokesperson told the Post it has assisted members with understanding the new rule and that there were hiccups with compliance at first because of the sheer size of the files being uploaded.

The rule was originally set to take effect Jan. 1, but CMS delayed implementation for six months over those compliance concerns.

In 2023, payers must start providing an internet-based price comparison tool that allows members to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers for 500 items and services. That comparison tool must be provided for all services by 2024.

Provider price disclosure rules went into effect at the start of 2021, but the majority of facilities have not complied. CMS warned 342 hospitals they were not in compliance in February and fined the first health system in June for violations.


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