PRA Submits Comments on the 2024 OPPS Rule
PRA submitted comments on the proposed rule for the Medicare Program Hospital Outpatient Prospective Payment System for 2024. We recommend additional, important changes to ensure that patients, employers, unions, and all consumers have the information they need to make critical decisions about health care services and coverage.
Require the “Consumer-Friendly Expected Allowed Amount” to Be an Actual Price, and Require Hospitals to Disclose Their Pricing Formulas. The proposed requirement that hospitals disclose the “consumer-friendly expected allowable charge” for a service does not go nearly far enough to guarantee that the patient would obtain a usable expected dollar amount to be charged. We suggest that CMS require hospitals to share accurate, upfront prices of items and services, along with the percentage or algorithm on which the price is based, and hold them accountable for these prices.
Prohibit the Use of “Not Applicable” or Blank Fields in Lieu of Standard Charges. Hospitals’ egregious use of “not applicable,” “N/A,” or blanks when required to provide standard charge information must be addressed. We recommend that hospitals only be permitted to use “not applicable” when the items or services in question are not furnished by the hospital.
Eliminate the Price Estimator Tool Loophole. Internet-based price estimator tools are deceptive and are a loophole to avoid providing patients with upfront prices in a consumer- friendly manner. We recommend that price estimator tools no longer be deemed in compliance with 45 C.F.R. Part 180. To provide patients with financial certainty, estimator tools must not be permitted in lieu of actual prices.
Make Machine-Readable Files (“MRFs”) Accessible and Readable by Both Machines and Humans. MRFs must be accurate, complete, and usable data files that are available and easily accessible in both machine-readable and human-readable format. JSON files are not useful for consumers and employers and require the added cost of a third party to interpret and make meaningful. We suggest that CMS require the use of only spreadsheet formats (such as CSV files) to ensure that consumers, employers, and union plans can access this valuable information without having to pay middlemen to translate the data for their use.
Require Hospitals to Include All Billing Codes, Including CPT, HCPCS, DRG, and NDC. To allow for price comparisons across hospitals, providers, and plans, hospitals must be required to provide all codes and code modifiers that are associated with the standard charges of the items and services offered. The Proposed Rule’s elimination of “including but not limited to CPT, HCPCS, DRG, and NDC”, as a modifier to “any code used by the hospital” is a step backwards in that it may enable hospitals to use proprietary codes that prevent standardized comparability across pricing information.
Require Attestations to the Accuracy and Completeness of the Content of Disclosures under the Hospital Price Transparency Rules. Without attestation by a senior officer of the hospital as to the accuracy and completeness of price transparency disclosures, hospitals will continue to provide misleading and inaccurate information to patients, including providing inaccurate “estimates.” We appreciate that attestation was included in this Proposed Rule, and encourage you to deem such attestations as material to payment from the federal government to incorporate potential liability under the False Claims Act (“FCA”) for hospitals that knowingly violate the rule and falsely attest to the accuracy and completeness of their files.
Strengthen CMS’s Enforcement. Assessment of noncompliance is only productive when paired with effective, frequent, and timely enforcement as a consequence for noncompliance. We recommend that CMS enhance its enforcement mechanisms and penalties for noncompliance with hospital price transparency rules set forth at 45 C.F.R. Part 180. We suggest that CMS use the word “enforcement,” not “assessment,” throughout the regulatory text set forth in §180.70.
Expand the Application of Hospital Price Transparency Rules to all Items and Services Furnished by Affiliates, Subsidiaries, and other Providers Operating within the Same Health System or Enterprise. Hospitals should not be allowed to avoid price transparency requirements through the provision of care via affiliates, subsidiaries, and other providers operating within the same system.
Expand the Price Transparency Requirements to Ambulatory Surgery Centers, Imaging Centers, and Laboratories. Ambulatory Surgical Centers (“ASC”) play an increasingly important role in patient care and provide many of the same items and services as hospitals, and imaging centers and laboratories furnish services that significantly impact the overall cost of care. We suggest you hold ASCs, imaging centers, and laboratories to the same price transparency standards as hospitals to ensure that healthcare consumers can make informed decisions and lower their costs.
Require Hospitals to Publicly Post their Charity Care or Financial Aid Policies in a Manner Accessible to Patients. Hospital policies regarding charity care and financial aid should be readily available to patients as a means of increasing hospital price transparency and providing patients with financial certainty.
Require Hospitals to Post a Discounted Cash Price and Accept Cash Regardless of Insurance Coverage. Hospitals must be required to post accurate discounted cash prices and to accept cash payment from individuals who choose to pay the discounted cash price, regardless of whether such individuals have coverage.
Provide Notice to the Public. A fully informed and aware public is the strongest defense against false and misleading healthcare price information. We encourage the Biden Administration to inform all individual consumers and employers that they have the right to real and accurate prices from hospitals where they seek care.
Read the full comment letter here.