cms’s chargemaster posting requirement: implications and ... · information (called the...

CMS’s Chargemaster Posting Requirement:

Implications and Best Practices

Chad Mulvany, FHFMAPolicy Director, Healthcare Financial Practices

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Agenda

1) How Did We Get Here?

2) What’s the Requirement?

3) Price Transparency Best Practices

4) Closing Comments

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0%

113%

270%

0%24%

47%

0%

100%

200%

300%

1999 2007 2017

Worker's Contribution to Premiums Worker's Earnings

Cumulative Increases in Family Premiums and Workers Earnings

1999 - 2017

Depressed WagesHealthcare Cost Increases Are Limiting Income Growth for Many Americans.

How Did We Get Here?

$0

$5,000

$10,000

$15,000

$20,000

Single Coverage Family Coverage

Average Premium for Covered Workers2017

Source: Kaiser Family Foundation

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Increasing Out-of-PocketOver the Past Decade, Deductibles Have Tripled.


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15% 19% 30% 36%

100% FPLIncome: $ 24,250 Liquid Assets $700

200% FPLIncome: $ 48,500 Liquid Assets: $1,500

300% FPLIncome: $ 72,750 Liquid Assets: $3,426

400% + FPLIncome: $ 97,000 Liquid Assets: $18,343

Percentage of US Population By Federal Poverty Level Family of Four

Priced OutMany Households Can’t Afford Costs Related to Health Care.

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Examples When Charges Matter:

• Uninsured but ineligible for financial assistance.

• Uninsured Individuals who receive partial financial assistance.

• Services received from out-of-network providers.

• Cost sharing for percent of charge contracts.

Patient ImpactWhile Few Patients Are Asked to Pay Full Charges, the CDM “List Price” Increases Healthcare Costs for Some Patients.

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The Foundation of Trust Is Eroding

36% 16%23%

Physicians and nurses

Hospitals Health insurance plans

Percentage of respondents who agree that the following entities “put patients over profits”

Source: www.theharrispoll.com/health-and-life/Pharma-Biotech-Patients-Over-Profits.html

Affordability Issues and Pricing Opacity Is Eroding the Public’s Degree of Trust in Providers…


http://www.theharrispoll.com/health-and-life/Pharma-Biotech-Patients-Over-Profits.html

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Seeking Alternatives…Opening Patients and Consumers to Both Market Based and Political Alternatives.


Market Based Alternatives Political Alternatives

Democrats Offer ‘Medicare for All’ Bill to Transform Health CareA leader of House Democrats’ progressive wing introduced “Medicare for all” legislation Wednesday that would replace almost all private health insurance, an idea that’s galvanizing the party’s liberal base and winning endorsements from many of its top presidential contenders. She unveiled the 120-page Medicare for All Act of 2019 at a Capitol news conference Wednesday with 107 co-sponsors, after saying she received assurances from Democratic leaders that the Budget Committees would hold hearings on it.

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwiav5_S0OHgAhWi8oMKHS3UCOwQjRx6BAgBEAU&url=%2Furl%3Fsa%3Di%26rct%3Dj%26q%3D%26esrc%3Ds%26source%3Dimages%26cd%3D%26ved%3D%26url%3Dhttps%253A%252F%252Fwww.bloomberg.com%252Fmarkets%252Fstocks%26psig%3DAOvVaw2Cv63l3u7NJGIAFgM_k0Tw%26ust%3D1551553310837023&psig=AOvVaw2Cv63l3u7NJGIAFgM_k0Tw&ust=1551553310837023

https://www.scribd.com/document/400662193/Medicare-for-All-Act-of-2019-Jayapal

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Agenda




4) Closing Comments

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Legislative TextCMS in the 2019 IPPS Final Rule Added the Requirement that Chargemasters Posted to the Internet Must be Machine Readable in Response to Perceived Non-Compliance.

What’s the Requirement?

‘‘STANDARD HOSPITAL CHARGES.—Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act.”

Section 2718 (e) of the Public Health Service Act

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CMS Guidance CMS Has Released Two FAQs Clarifying the Requirement for Hospitals to Post Charges.


Does CMS Require A Specific Format?

What Qualifies as Machine Readable?

What Information Needs to Be Posted?

Which Hospitals Are Required to Comply?

What Happens if A Hospital Doesn’t

Comply?

Key Questions Addressed by CMS’s FAQ

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Sources: 1) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/FAQs-Req-Hospital-Public-List-Standard-Charges.pdf2) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/Downloads/Additional-Frequently-Asked-Questions-Regarding-Requirements-for-Hospitals-To-Make-Public-a-List-of-Their-Standard-Charges-via-the-Internet.pdf

Presenter

Presentation Notes

Which hospitals are required to comply?: All of them in the US, even if you are reporting charges to a state database. This includes psych hospitals, critical access hospitals, sole community hospitals… What happens if my hospital doesn’t comply? The hospital will not be in compliance with the law. In the FY 2019 IPPS/LTCH proposed rule (83 FR 20549), CMS sought comment on the most appropriate mechanism for CMS to enforce price transparency requirements. As indicated in the FY 2019 IPPS/LTCH PPS final rule (83 FR 41686), specific additional future enforcement or other actions that we may take with the guidelines will be addressed in future rulemaking. What information needs to be posted? it is the responsibility of the hospital to establish (and update) and make public a list of the hospital’s standard charges for all items and services provided by the hospital, including all drugs, biologicals, and all other items and services provided by the hospital. This includes items that are not in the chargemaster Are hospitals required to use a specific format?: No, it is up to the hospital as long as the data reflects the current standard charges as reflected in the CDM. However, a subsequent answer encourages hospitals to use a consumer friendly format. What does machine readable mean: CMS excludes posting charges in pdf format but again leaves it up to the hospital. It specifically cites .xml and .csv formats as machine readable

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/FAQs-Req-Hospital-Public-List-Standard-Charges.pdf

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New ScrutinyMedia Outlets Around the Country Are Identifying, Highlighting, and Calling into Question Significant Charge Variances.


$3,407$2,858

$8,534

$0

$3,000

$6,000

$9,000

CommunityHospital

AMC A AMC B

Price Range of a Liter of IV Fluid

$264 $272

$383

$0

$100

$200

$300

$400

$500

CommunityHospital

AMC A AMC B

Price Range of a Semi-Private Room

Presenter

Presentation Notes

Saline off the web Barrel of brent crude Cost to fill up a 20 gallon gas tank https://californiahealthline.org/news/transparent-hospital-pricing-exposes-wild-fluctuation-even-within-miles/?

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Tell Your StoryHFMA Has Developed FAQs to Help Health System Executives Address Media Questions About the Charge Setting Process.


The FAQs are available at: hfma.org/transparency

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A Matter of PerspectiveWhile Requirement Exposes Hospitals to Scrutiny, It’s Also an Opportunity to Provide Consumers with Meaningful Price Transparency that Will Improve the Experience of Care.


"Hospitals don't have to wait for us to go further in helping their patients understand what care will cost."

Seema VermaCMS Administrator

A Floor, Not a Ceiling

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Naming and ShamingCMS’s enforcement efforts to date rely on crowdsourced reports on the Twitter site #Where’sthePrice.

CMS chief Seema Verma tweets '#WheresThePrice' challenge in price transparency push

CMS Administrator Seema Verma addressed what she called the "Twitterverse" in a tweetJan. 18, asking individuals to participate in the agency's "#WheresThePrice" price transparency challenge.

"As our latest #PriceTransparency initiative begins to take effect, we're asking the Twitterverse to help us make sure patients have access to the basic hospital pricing information (called the chargemaster) that is now required to be posted online," she wrote.

Ms. Verma's tweet was accompanied by an image that reads: "Here's the challenge: Visit the website of your local hospital. If you can't find their pricing information posted in an electronic format, let me know. Send me a tweet with the hashtag #WheresThePrice and help us drive #PriceTransparency!"

Source: https://www.beckershospitalreview.com/finance/cms-chief-seema-verma-tweets-wherestheprice-challenge-in-price-transparency-push.html


Presenter

Presentation Notes

At the agency-initiated Twitter site #WheresthePrice, a dialogue has ensued. In one case, a Texas man, Matt Kleiber, checked 31 hospitals and medical centers in Houston and found one health system, Memorial Hermann, which operates 16 hospitals, not in compliance. MH has posted their MS-DRGs and believed they were in compliance. They have subsequently posted their CDMs. Other reports of noncompliance at #WheresthePrice appeared to be the result of incomplete website explorations by consumers. A KHN check of the websites of six cited hospitals showed the price lists were posted. On all but one of the sites, however, the information was not prominently displayed.

https://twitter.com/SeemaCMS/status/1085665784532209664

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What’s Next?The ONC proposed “Promoting Interoperability” rule included a “request for information” on requiring the public disclosure of negotiated rates.

Trump Administration Weighs Publicizing Secret Rates Hospitals and Doctors Negotiate With Insurers

The Trump administration is sounding out the medical industry on requiring hospitals, doctors and other health-care providers to publicly disclose the secretly negotiated prices they charge insurance companies for services, a move that would expose for the first time the actual cost of care.

The U.S. Department of Health and Human Services is seeking public comment on whether patients have a right to see the discounted prices in advance of obtaining care, federal officials said. The invitation for comment—outlined in a little noticed passage of a broader patient-data proposal released last month—is a major step toward a possible rule that could require providers to release such information, they said.

Source: https://www.wsj.com/articles/trump-administration-weighs-publicizing-hospital-rates-negotiated-with-insurers-11551990505?


https://www.regulations.gov/document?D=HHS-ONC-2019-0002-0001&mod=article_inline

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Agenda




4) Closing Comments

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Price Transparency Best Practice

HFMA Price Transparency Task Force

Presenter

Presentation Notes

The task force included representatives from America’s Health Insurance Plans, CHA, the American Hospital Association, Catalyst for Payment Reform, Community Health Advisors, and the other groups shown here, including a patient.

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HFMA Price Transparency Task Force Report

• Clarifies basic definitions that are often misused

• Sets forth guiding principles• Establishes roles for payers,

providers, others• Reflects consensus of key

stakeholders

Available at: hfma.org/transparency

Presenter

Presentation Notes

The task force reached consensus on how consumers can obtain clear and easy-to-understand information about their financial obligation for healthcare services—before any tests or procedures are performed. The report starts by clarifying definitions and goes on to set forth guiding principles and recommendations for price transparency that highlight how hospitals, physicians, and health plans can share reliable information on healthcare prices with consumers. Combined with other relevant information, such as quality and safety, price information will help consumers make more informed healthcare decisions.

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Definitions of Key Terms

• Cost varies by the party incurring the expense.• Charge is the dollar amount a provider sets for

services rendered before negotiating any discounts.

• Price is the total amount a provider expects to be paid by payers and patients for healthcare services.

Cost, charge, and price should not be used as interchangeable terms.

Presenter

Presentation Notes

A lot of the confusion about healthcare pricing stems from confusion about terminology. In the media, you tend to see cost, charge, and price used interchangeably, but in reality these have very different meanings in health care. Take the term Cost. To the patient, cost is the amount payable out of pocket for healthcare services, which may include deductibles, copayments, coinsurance, amounts payable by the patient for services that are not included in the patient’s benefit design, and amounts balance billed by out-of-network providers. To the provider, cost is the expense (direct and indirect) incurred to deliver healthcare services to patients. To the insurer, cost is the amount payable to the provider (or reimbursable to the patient) for services rendered. To the employer, cost is the expense related to providing health benefits (premiums or claims paid). The task force recommends avoiding the term cost when talking about payment, because it means different things to different people. [Read through the definitions of charge and price.] Price is the term that is best for referring to what any individual will be expected to pay.

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An Actionable Definition of Price Transparency

Readily available information on the price of healthcare services, that, together with other information, helps define the value of those services and enables patients and other care purchasers to identify, compare, and choose providers that offer the desired level of value.

Presenter

Presentation Notes

And that brings us to a working definition of price transparency, which you see here. It’s important to keep in mind why we’re working toward price transparency. The goal is to provide patients and other care purchasers with the information they need to make an informed choice of provider.

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Guiding Principles

Price transparency information should:

• Empower patients and other care purchasers to make meaningful price comparisons

• Be easy to use and easy to communicate• Be paired with other information that defines the value of

services for the care purchaser• Enable patients to understand the total price of their care and

what is included in that price

Price transparency will require the commitment and active participation of all stakeholders.

Presenter

Presentation Notes

Price transparency information should empower people to compare prices among providers. It should be easy to use and to communicate. Price information should be presented along with quality and safety information. And price transparency information should enable patients to understand the total price of their care and what that price includes. That’s a tall order and it’s going to take commitment and participation from all of us.

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Roles for Key Stakeholders

• Health plans should serve as the principal source of price information for their members

• Providers should be the principal source of information for uninsured patients and out-of-network care

• Referring clinicians should use price information to benefit patients

• All stakeholders can offer a price information resource to consumers

Presenter

Presentation Notes

What does that mean? Here’s an overview. Health plans have a key role, in fact should serve as the principal source of price information for their members. Providers should be the primary source for the uninsured and for people who are seeking care out of network. Physicians and other clinicians should make use of price information for the benefit of their patients. And everyone who has contact with consumers can make a new HFMA consumer price information guide available to them. I’ll tell you more about that in a moment.

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Health Plan Role

• The total estimated price of the service

• Clear indication of whether a particular provider is in the health plan’s network.

• Clear statement of the patient’s estimated out-of-pocket payment responsibility

• Other relevant information on the provider or service sought

Health plans should serve as the principal source of price information for their members. Tools for insured patients should include:

Presenter

Presentation Notes

Because health plans will, in most instances, have the most accurate data on prices for their members. And many, if not most, health plans already offer online or telephone-based price transparency tools. Employers with self-funded health plans have the option of working with health plans (which often serve as third-party administrators for self-funded plans) or other vendors in developing transparency tools for insured employees and their dependents. To be most useful, these tools should have all the information you see listed here. Total estimated price. The price estimate for in-network services is a communication between the health plan and the insured patient and should follow the form of an explanation of benefits, representing the total estimated price (i.e., the plan’s negotiated rate for the service) as a dollar amount, not as a percent discount from charges, to avoid confusing the patient. For services received from out-of-network providers, because the provider’s pricing information is not available to the health plan, the health plan can only provide information about the benefit structure for that type of out-of-network care (e.g., a 20 percent co-insurance obligation). Network status. The tool should provide a clear indication of whether a particular provider is in network and information on where the patient can try to locate an in-network provider, such as a list of in-network providers that offer the service. Out-of-pocket responsibility. Another essential element is a clear statement of the patient’s estimated resulting out-of-pocket payment responsibility, tied to the specifics of the patient’s health plan benefit design, including coinsurance and the amount of deductible remaining to be met (as close to real time as possible). Other relevant information. Information related to the provider or the specific service sought (e.g., clinical outcomes, patient safety or satisfaction scores) should be included where it is available and applicable. This information should clearly communicate what has been measured and to whom the measurement pertains (e.g., to the facility, the physician, etc.)

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Provider Role

• Offer an estimated price for a standard procedure and make clear how complications may increase the price.

• Clearly communicate pre-service estimates of prices.

• Clearly state what services are included in an estimate.

• Give patients other relevant information, where available.

For uninsured patients and out-of-network care, providers should:

Presenter

Presentation Notes

The provider should be the principal source of price information for uninsured patients and patients who are seeking care from the provider on an out-of-network basis. For these patients, the provider should offer the following: Estimated price. Prices in most instances will take the form of an estimate; that is, provide a price for a standard procedure without complications and make clear to the patient the services included in the price and how complications or other unforeseen circumstances may increase the price. What’s included/excluded. Providers should clearly communicate to patients what services are and are not included in a price estimate. If any services that would have significant price implications for the patient are not included in the price estimate, the provider should try to provide information on where the patient could get this information. Other relevant information. Some states have begun to make both price and quality data available on public websites and encourages all states to furnish such information on providers. A number of public and private organizations also offer public access to data on patient outcomes, safety, and patient satisfaction or credentialing information on providers who have met certain quality benchmarks. The price estimate that a provider gives to patients can reference and provide links to various reliable websites where the provider knows relevant information is available. In general, price transparency for the uninsured is subject to a substantial and expanding number of laws at both the federal and state levels and it is the first responsibility of providers to ensure that that policies and practices adhere to these legal requirements. Regardless of legal requirements, however, it is in a provider’s best interest to be proactive in its approach to price transparency because: A growing number of patients face significant financial responsibility for healthcare services and are becoming increasingly price sensitive. As consumer price sensitivity has intensified, so too has media attention to healthcare prices. Providers that can speak accurately and confidently about their prices will be better positioned to succeed in this environment than providers that can only refer back to their charge schedule.

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All Stakeholders Can Offer a Pricing Resource to Consumers

hfma.org/consumerguide


• Describes how to request price estimates, step by step

• Clarifies what estimates may or may not include

• Explains in-network and out-of-network care• Defines key terms• Available for posting on your website at no

charge• Hardcopies available for purchase in bulk at a

nominal price through AHA’s online store

Presenter

Presentation Notes

This is the consumer resource on pricing that I mentioned earlier. It was developed by a working group of the task force, including CHA, to make it easier for consumers to get price estimates ahead of service and navigate their way through the price information that’s out there. Providers are encouraged to post this guide on the billing and payment section of their website. You can download the PDF from HFMA’s website at hfma.org/consumerguide. Or buy hardcopies through the American Hospital Association’s online store. They are priced at $20 for 10 copies. Distribute them in the patient financial services department or in outpatient areas or physician offices. It’s a great way to demonstrate your commitment to sharing price information with your community.

• Helps consumers understand questions to ask to avoid surprise bills

• Features examples of common procedures

• Includes practical tools and tips

Consumer Education Should Extend to Avoiding Surprise Out-of-Network Bills

hfma.org/consumerguide

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Not HelpfulWhile This Meets the Technical Requirements of the Regulation, It Does Not Provide Useful Information to Consumers.


Example of One Health System’s Compliance Efforts

{"CDM":[{"FACILITY":"ABMC","CMS_PROV_ID":"XXXXX","HOSPITAL_NAME":"ABC Medical Center - ABC Medical Center","SERVICE_SETTING":"DRG","CDM":"DRG-064","DESCRIPION":"INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC","REVENUE_CODE":"","CHARGE":94946.00},{"FACILITY":"ABMC","CMS_PROV_ID":"XXXXX","HOSPITAL_NAME":"ABC Medical Center - ABC Medical Center", "SERVICE_SETTING":"DRG", "CDM":"DRG-189","DESCRIPION":"PULMONARY EDEMA & RESPIRATORY FAILURE", "REVENUE_CODE": "“, "CHARGE“ :52947.00}, {"FACILITY": "ABMC", "CMS_PROV_ID":"XXXXX HOSPITAL_NAME": "ABC Medical Center - ABC Medical Center", "SERVICE_SETTING": "DRG", "CDM":"DRG-190", "DESCRIPION":"CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC", "REVENUE_CODE":"", "CHARGE":54264.00},

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A Better ApproachThe University of Utah Health System meets the CMS requirements by posting their CDM in an accessible “easy” to understand manner and encourages patients to contact the health system for an estimate of prices.


Source: https://healthcare.utah.edu/pricing/

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Provide Easy Access to InformationIn addition to meeting the posting requirement, Unity Point arms patient financial counselors with the tools to provide price estimates and makes them readily available.


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Automate High Volume ServicesUniversity of Colorado Health makes it possible to receive an estimate, by location and payer, for select common services via the web and a mobile app.


Source: https://www.uchealth.org/billing-and-pricing-information/

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One Stop ShoppingUniversity of Utah Health’s estimate provides cost sharing for both the professional and technical component.


Source: https://healthcare.utah.edu/pricing/calculate.php#/

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Providing AssistanceThey provide a link to financial assistance materials.


Source: https://healthcare.utah.edu/pricing/calculate.php#/procedure/CTSCANABDOMEN

Presenter

Presentation Notes

The one rock I’d throw at this is it doesn’t provide detail on what the average allowable means. Also, the caveat could be stronger.

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Duly NotedMayo Clinic’s estimates provide appropriate caveats to help patients understand the limits of their price estimator tool.


Source: https://costestimator.mayoclinic.org/carepaths/257/Rochester/cost?

Presenter

Presentation Notes

The one rock I’d throw at this is it doesn’t provide detail on what the average allowable means. Also, the caveat could be stronger.

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Make It KnownSaint Alphonsus Health System’s CEO used an op-ed article to raise awareness in the community about how to receive a price estimate.


Understanding cost transparency from the perspective of a Catholic health care system

Using the price estimator tool is a good first step, but we highly recommend calling your insurance carrier or hospital registration team for more personalized information. At Saint Alphonsus, our Patient Registration Team can be reached at 208-367-COST (or 888-204-2678 toll free) to get the most accurate estimate of the cost of your care and out-of-pocket expenses. Representatives will meet with you to discover important variables in your care decision. These include the following, to name a few:

▪ Scope of the specific service or procedure. ▪ Physician or team of specialists involved.▪ Insurance coverage.▪ Preferred location for the service.

To learn more, visit www.saintalphonsus.org/online-price-estimator.

Source: https://www.idahostatesman.com/opinion/readers-opinion/article225205395.html

Presenter

Presentation Notes

The recent article titled, “Treasure Valley hospitals must now reveal their prices. Will checking online help? Maybe” by Idaho Statesman’s Audrey Dutton raised valuable insights and suggestions for individuals seeking online pricing for health care services. As the president and CEO of Saint Alphonsus Health System, our region’s only Catholic health care ministry that offers mission-driven care as a ministry of healing, I would like to offer a unique perspective to this issue of price transparency. First, Catholic health care is rooted in the conviction that mission-driven health care is a ministry of healing and is not in the business of selling a service or commodity. Buying health care is much more complicated than buying services or large items such as a car or home. It is a much deeper personal experience and decisions have lifelong consequences, not only for the individual, but also for family and loved ones. In Catholic health care, our focus is on the dignity of the patient, and we do not view patients as “consumers or shoppers.” Health care is a necessary service to prevent illness and/or to restore well-being. Second, at Saint Alphonsus, the issues of access and transparency are an important part of our People Centered Care philosophy, which puts our patients at the core of our treatment decisions. For patients, a trusting relationship with a provider and caregiver is a vital element in determining service decisions. Physicians and hospital staff guide patients through their journey, and work together to discover patient’s specific needs for a course of treatment. ADVERTISING inRead invented by Teads Third, as Audrey Dutton outlined in the article, there are a number of variables that determine a patient’s out-of-pocket expenses; thus, the “price” for a medical procedure may vary for different people, and across institutions. One must consider the type of insurance benefits an individual has to more accurately understand the true cost. Sign Up and Save Get six months of free digital access to The Idaho Statesman SUBSCRIBE WITH GOOGLE #ReadLocal Using the price estimator tool is a good first step, but we highly recommend calling your insurance carrier or hospital registration team for more personalized information. At Saint Alphonsus, our Patient Registration Team can be reached at 208-367-COST (or 888-204-2678 toll free) to get the most accurate estimate of the cost of your care and out-of-pocket expenses. Representatives will meet with you to discover important variables in your care decision. These include the following, to name a few: ▪ Scope of the specific service or procedure. ▪ Physician or team of specialists involved. ▪ Insurance coverage. ▪ Preferred location for the service. In closing, we applaud the Statesman’s article informing the public about this new CMS rule and move toward improved transparency. We look forward to continuing to serve as a resource in empowering our community with tools and resources to make informed decisions regarding their health care. To learn more, visit www.saintalphonsus.org/online-price-estimator. �Read more here: https://www.idahostatesman.com/opinion/readers-opinion/article225205395.html#storylink=cpy

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Agenda




4) Closing Comments

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Closing CommentsThe charge posting requirement presents a unique opportunity to position your organization to be more consumer centric.


Perspective Matters

Multiple Ways to Meet Consumer Needs

Link to Financial Assistance Policy

Communicate Clearly and Frequently

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Build Your Organizational Capabilities Adopt Best Practices

hfma.org/dollars


http://www.hfma.org/dollars/

[email protected]

@hfmaorg

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