Checkup: What is Price Transparency

Details of the Consolidated Appropriations Act of 2021:

As of January 1, 2021, healthcare providers are required to provide price transparency to their patients on their websites. The new law requires hospitals and other healthcare providers to list pricing for at least 300 shoppable services, 70 of which are required by the Centers for Medicare & Medicaid Services (CMS). 

To be fully compliant, a hospital or healthcare facility must have:

• A complete machine-readable standard charges file which meets the following criteria
  • Codes–the mandated codes used for accounting or billing purposes for each of its items and services
  • Gross Charge–gross charges for at least 50% of the items and services identified
  • Discounted Cash Price–cash prices (if a patient were to pay for the service without insurance) for at least 50% of the items and services identified
  • Negotiated Minimum–the de-identified minimum negotiated charge for at least 50% of the items and services identified (De-identification removes all direct identifiers from patient data and allows organizations to share it without the potential of violating HIPAA).
  • Negotiated Maximum–the de-identified maximum negotiated charge for at least 50 percent of the items and services identified
  • Negotiated Rates–the payer-specific (the health insurance company) negotiated charge that applies to each item or service, for at least 50 percent of the items and services identified
  • Payer and Plan–all payer-specific negotiated charges (for all payers and plans at the hospital) in a manner clearly associated with the name of the third-party payer and specific plan, for at least two payers including Blue Cross Blue Shield, United, Cigna, Anthem, or Humana
• A user friendly 300 Shoppable Services list or An Online Price Estimator Tool
  • 300 Shoppable Services List–a list of 300 shoppable services is posted
  • Price Estimator Tool
    • Required if there is no list of the 300 Shoppable Services
    • The price estimator tool must provide cash prices for items or services that are accessible by an uninsured person

See some of our work.

Good Shepherd RehabPenn Partners