Most Healthcare Pricing Transparency Vendors
are not in Full CMS Compliance & Their Hospital Clients Risk Heavy Fines

 

No Cost Vendors Can Equal No Comply

 

Per the CMS guidelines of August, 2021 "Pricing cannot be created from aggregate or average charges."

 

RevenueMasters offers full compliance with contract modeling

 

Download Free Turnkey Solution Kit

 

View Demo

Most Healthcare Pricing Transparency Vendors
are not in Full CMS Compliance & Their Hospital Clients Risk Heavy Fines

 

No Cost Vendors Can Equal No Comply

 

Per the CMS guidelines of August, 2021 "Pricing cannot be created from aggregate or average charges."

 

RevenueMasters offers full compliance with contract modeling

 

Download Free
Turnkey Solution Kit

 

View Demo

CMS Mandate - Possible Fines! - Must Use Contract Modeling

 

On January 1, 2021 the CMS mandated hospitals provide their services pricing transparency via a "Patient Facing Website" or face a $300 daily fine per facility.

 

It's proposed to INCREASED! A full year of non-compliance could soon range from
$109,500 to $2,007,500 per hospital.

BEWARE MANY VENDORS ARE NOT IN COMPLIANCE CONTRACT MODELING IS REQUIRED

Per the CMS guidelines of August, 2021 pricing cannot be created from aggregate or average charges

 

 

Timeline and Application of New Surprise Billing and Transparency Laws and Rules


This chart below compiles all recent laws and rules concerning healthcare price transparency as of
December 30, 2020. Providers should consult with legal counsel as to the application of any
particular law or regulation to their health plan.

 

Hospital price transparency final rule
Hospitals must make public their standard charges online in two ways:

1. A comprehensive machine-readable file that includes charges for all hospital items and service.

2. A consumer-friendly display that includes the charges for at least 300 "shoppable" services

3. Do not create averages or aggregate charges.

4. Do not create standard charges from prior claims or reimbursement information.

January 1, 2021
Hospitals
 
Group health plan transparency rule for public disclosure
Plans must make public the following information online using three machine-readable files:

1. In-network rates

2. Out-of-network allowed amounts and

3. Prescription drug negotiated rates

Plan years beginning on or after January 1, 2022
Non-grandfathered group health plans and health insurers. Does not apply to grandfathered plans, amounts and account-based plans, excepted benefits (e.g.,dental/vision), short-term limited duration insurance or retiree-only plans
 
Group health plan transparency rule for disclosures to  participants and beneficiaries
Plans must provide cost-sharing information and rate information that is accurate at the time of the request to participants on a searchable, internet-based, self-service tool; and must provide a notice when the tool is used.
Plan years beginning on or after January 1, 2023 for 500 items and services
Non-grandfathered group plans and health insurers. Does not apply to grandfathered plans, account-based plans, excepted benefits (e.g., dental/vision), short-term health limited duration insurance or retiree-only plans
 
No Surprises Act: emergency services
Plans must cover emergency services at non-participating facility, services/items provided by non-participating provider at a participating facility, or non-participating provider air ambulance services with the same participant cost-sharing whether the services are from a participating or non-participating provider or facility. Providers and facilities are banned from balance billing.
Plan years beginning  on or after January 1, 2022
Group health plans* and health insurers
 
No Surprises Act: independent dispute resolution
Plans must pay non-participating providers within 30 days or deny payment. Parties may request independent dispute resolution
Plan years beginning on or after January 1, 2022
Group health plans and health insurers
 
No Surprises Act: qualifying payment amount
Federal agencies must issue rulemaking establishing the amount methodology to determine "qualifying payment amount," differentiating by large and small group markets.
No later than July 1, 2021
 
 
ID card requirement
Plans must include plan deductibles, out-of-pocket (OOP) maximums and consumer assistance contact information (phone number and website) in clear writing on any physical or electronic plan or insurance identification card.
Plan years beginning on or after January 1, 2022
Group health plans and health insurers
 
External review
External review applies to adverse determinations concerning emergency services or air ambulance services covered by the No Surprises Act.
No later than January 1, 2022
Unclear — probably non-grandfathered group health plans and insurers
 

 

* Covered group health plans generally include those subject to federal health care reforms under ERISA, the Internal Revenue Code and the Public Health Service Act. Certain health plans otherwise excepted from federal health laws, e.g., small group health plans, excepted benefits and retiree-only plans, would appear to be exempt from these requirements, but applicability should be clarified in regulatory guidance. It appears that the requirements of this law apply to grandfathered group health plans, but this should also be addressed in regulatory guidance.

 

Provider fee disclosure
When a patient schedules a service, providers must provide a timely notification in clear and understandable language of the good-faith estimate of the expected charges for providing items and services to the plan or insurer (or if uninsured, the individual).
January 1, 2022
Healthcare providers and facilities
 
Advanced Explanation of provider/facility of estimated Benefits disclosure
After receiving notice provider/facility of estimated charges, plans must provide the participant an Advanced Explanation of Benefits (EOB) including rate and cost-sharing information.
Plan years beginning on or after January 1, 2022
Group health plans and health insurers
 
Notice of continuity of care
Plans must notify individuals who are "continuing care patients" of the right to continue to receive care after termination of a provider/facility contract. The notice places rules on contract terms and plan rules.
Plan years beginning on or after January 1, 2022
Group health plans and health insurers
 
Provider directory requirements
Plans must create a process to verify the accuracy of their provider databases and update at least every 90 days. If the participant was informed the provider was a participating provider when in fact a non-participating provider, the plan cannot impose higher cost-sharing that would apply for participating provider, and must apply the participating deductible and OOP.
Plan years beginning on or after January 1, 2022
Group health plans and health insurers
 
Gag clauses prohibited
Plans may not enter into an agreement with a provider,network, TPA or other service provider that would directly or indirectly restrict the plan from providing provider-specific cost or quality information to referring providers, plan sponsors, participants or electronically accessing de-identified claims. Requires annual attestation of compliance
Unclear
Group health plans and health insurers
 
Disclosure of broker and consultant  compensation
Amends ERISA Section 408(b)(2) to require disclosure of compensation
December 27, 2021, with transition period for executed contracts
ERISA-governed plans
 
Mental Health Parity and Addiction Equity Act (MHPAEA) assessment required
Plans must perform and document comparative analyses of the design and application of non-quantitative treatment limitations (NQTLs) and make them available upon request to the secretary of the DOL or HHS as applicable
February 10, 2021 (45 days after enactment)
Plans subject to the MHPAEA
 
Reporting on prescription drug costs
Plans must submit prescription drug cost information to the federal government.
No later than December 27, 2021; for each year thereafter, no later than June 1

 

Unclear — probably non-grandfathered group health plans and insurers
 

 

For questions or to set up a free consultation intro call contact rick@revenuemasters.com or call direct at 877-591-2590 or BOOK INTRO CALL

RevenueMasters offers turnkey SaaS and services compliance solutions.

This resource is for informational purposes only and does not constitute legal, tax or investment advice. You are encouraged to discuss the issues raised here with your legal, tax and other advisors before determining how the issues apply to your specific situations.

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What Was The Purpose For the CMS Mandate?

 

Recognizing that surprise billing leaves patients feeling stressed out and anxious, CMS price transparency executive order will end ‘balance billing’, where patients are billed the difference between what providers charge and what insurers will pay. These bills often come as a shock, firstly because the patient didn’t expect the bill in the first place and secondly, because the complexities associated with healthcare expenses create opacity around the actual cost of care. e more about your product or service. How can you benefit them?

 

Our team models hospital providers, third-party and government contracts then work in partnership to customize pre-service pricing which allows them to provide their patients with personalized pricing data before care is delivered.

 

Revenue Masters combines the cost of services and the payer specific negotiated rates for accurate price transparency. Companies that do not have payer contract modeling software to model payer specific rates will not be able to provide hospitals with accurate pricing for pre-service and shoppable services which places hospitals at risk of providing inaccurate data and loss of revenue.

 

Healthcare providers need to act now to address this mandate. Additionally, providers will need to develop an integrated strategy that aligns charges, prices and out-of-pocket costs.

 

All in, transparent pricing is an increasingly useful strategy to improve revenue alongside patient satisfaction.

 

 

"We added contract management onto our existing system. The executive dashboard includes status and charts with the complete revenue cycle process in real-time, this helps us better visualize accounts and items that need attention. We are able to model various rate and term scenarios for better contract negotiations and improved financial performance. It saves us countless hours and we have the peace of mind that we are working our claims according to the complicated payer contracts."

 

– Joe Adams - Revenue Cycle Director / IT Director

 

For a Turnkey Pricing Transparency Solution Contact:
Revenue Masters
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877-591-2590

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