Payers must post negotiated prices starting today: 8 things to know

CMS' Transparency in Coverage final rule took effect July 1, requiring payers nationwide to publish the cost of nearly every healthcare service they've negotiated with providers.

 Eight things to know:

  1. The rule was set to take effect Jan. 1, but CMS delayed implementation for six months over concerns with the time and effort it would take payers to come into compliance with the new policy.

  2. 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.

  3. Prices must be posted in machine-readable files containing the following sets of costs for items and services:
    • In-network rate file: rates for all covered items and services between the payer and in-network providers.
    • Allowed amount file: allowed amounts for and billed charges from out-of-network providers.

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

  5. An enforcement exception will be granted when health plans using alternative reimbursement arrangements cannot accurately provide a specific dollar amount until after services are rendered. Those plans can instead list the formula, variables, methodology or other information about how the rate would be derived. 

  6. For contractual arrangements where a health plan agrees to pay an in-network provider a percentage of the billed charges and is not able to assign a dollar amount until a bill is generated, the plans may instead report the percentage number.

  7. In 2023, payers must provide 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, and for all services by 2024.

  8. 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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