During this webinar, we'll review CMS regulations and what’s required from providers for both Price Transparency and the No Surprises Act. We'll review strategies for implementation of both and talk about how CMS is currently responding to providers that haven't complied with Price Transparency requirements yet.

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Price Transparency and No Surprises Act:
Details You Need to Know
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Developed by Megan Smith
Executive Director of Quality and Training
msmith@hrgpros.com
509.789.6656

2. AGENDA
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Price Transparency CMS regulations - what's required
Strategies for selecting shoppable services
CMS' current response for non-compliance
No Surprises Act – what’s required
Ways to prepare for 1/1/22 go-live

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53% of consumers avoid seeking healthcare because they
don’t know how much it will cost
67% of patients want to shop for healthcare entirely online
61% of patients say their healthcare are more complex than
a mortgage payment
60% patients have gone to an appointment without
knowing if they could afford it
Source: https://www.changehealthcare.com/about/innovation/transparency

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5. Study Finds 5.6% Compliance
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80% Missing payer-
specific negotiated
charges
40% published
discounted cash
prices
52% did not
publish any
negotiated rates
19% presented 300
shoppable services;
however, several
incomplete
76% estimator tool
used; 11% didn’t
provide estimate
Source: https://www.beckershospitalreview.com/finance/94-of-hospitals-still-noncompliant-with-price-
transparency-rule-study-finds.html?utm_medium=email&utm_content=newsletter

6. Federal Ruling
• AHA failed to dispute the government has a
legitimate interest in promoting price
transparency and lowering healthcare costs
• Chargemaster requirement has not helped
improve transparency for consumers
• Evidence was clear that consumers are
frustrated with status quo
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December 29, 2020, federal appeals court ruled price
transparency rule can move forward on as planned on 1/1/2021

7. Regulations - Who
Facilities licensed as hospitals (Incl. CAHs) required to comply
• Physician services for employed physicians (no CMS guidance for
‘employed’ physicians. Refers to IRS employee designation)
• Separate offsite locations if prices are different
• Individual items, services and service packages in connection with
inpatient admission or outpatient dept. visit when standard charge has
been established
Federally owned or operated hospitals (IHS, VA, DOD)
considered in compliance already
• Charges non-negotiable publicized in advance
Source: https://www.cms.gov/files/document/hospital-price-transparency-frequently-asked-questions.pdf
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8. Regulations - Where
• Datasets must be displayed prominently on website
• Must be publicly available on website using CMS naming
convention
• Free of charge and easily accessible; not requiring an account
login/password
• Digitally searchable without providing personal information
• All data must be updated annually and publish date of last
update
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9. Regulations - What
Publicly Available All Service Dataset
• Machine readable chargemaster listing
• Gross charges
• Negotiated charges
• Self pay “walk-in rate”
• Minimum and maximum negotiated rate for all payors
Shoppable Service Dataset
• List of 300 shoppable services; incl. 70 CMS required
• Searchable and consumer friendly format
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10. All Service Dataset - Details
Standard Charges Hospitals Must Make Public
• Gross Charges: charge for an individual item or service that is reflected on
a hospital’s chargemaster, absent any discounts
• Discounted Cash Price: charge that applies to an individual who pays
cash, or cash equivalent, for a hospital item or service
• Payer-specific Negotiated: charge that a hospital has negotiated with a
third-party payer for an item or service
• De-identified Minimum Negotiated: lowest charge that a hospital has
negotiated with all third-party payers for an item or service
• De-identified Maximum Negotiated: highest charge that a hospital has
negotiated with all third-party payers for an item or service
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Q: What if the hospital does not provide a discounted cash price for
items and services?
• If hospital does not have a discounted cash price for self-pay consumers, the hospital
must post gross charges
Q: Items without associated HCPCS or CPT code; must these services
be listed?
• Yes. All hospital items and services with a standard charge must be listed. When an
item or service does not have a corresponding charge or diagnosis code associated, it
is acceptable to leave the information blank. Alternatively, a hospital could choose its
own indicator or other method to communicate to the public that no code is available
• Refer to Table 1 (84 FR 6558) for examples

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Q: If the hospital hasn’t provided the service in last 12 months, is
it still required to be reported?
• Yes. Hospitals must post standard charges (as applicable) for each item or
service with established standard charge
Q: How should hospitals display charges for services packages
that vary based on severity of illness (SOI)?
• The Final Rule does not limit hospitals from displaying additional clarifying
information for patients, for example, providing a base rate for each severity
level within a DRG or other clarifying information to patients related to how a
service package base rate may change depending on severity of illness (SOI)

13. Shoppable
Service
Dataset
Displayed prominently on publicly-available website
Free of charge, no login or password required
Searchable by service description, billing code and payer
A plain-language description of each shoppable service with primary
code used by the hospital for or billing the shoppable service
Use an indicator when one or more of the CMS-specified shoppable
services are not offered by the hospital (for example, N/A)
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Q: What is a shoppable service?
• Any service that can be scheduled by a healthcare consumer in advance. Examples:
joint replacements, physical therapy, hospital administration of medication , i.e., flu
shots or infusions
Q: What if hospital doesn’t provide one or more of the 70 CMS-
specified shoppable services or less than 300 shoppable services?
• Hospital must list as many shoppable services as provided and clearly indicate any
CMS-specified shoppable service that it does not provide. Hospital may use “N/A”
to indicate service is not provided

15. CMS Required 70 consists of four standard categories
Evaluation and Management Services
• Ex. Psychotherapy, New patient office visit, Patient office consult
Laboratory and Pathology Services
• Ex. Basic metabolic panel, obstetric blood panel, Kidney function
panel, manual urinalysis w/examination using microscope
Radiology Services
• Ex. Various CT or MRI scans, mammography, ultrasound
Medicine and Surgery Services
• Ex. Major joint replacement, cervical spinal fusion, endoscope, routine
obstetric care (vaginal or cesarean delivery)
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16. Selecting Shoppable Services
1. Start with 70-CMS required services
• Indicate with “N/A” any services/items not provided at hospital
2. Report services commonly provided at hospital to reach 300
3. Review reports at claim level (inpatient & outpatient) to track
volumes and common bundling
4. Inpatient DRGs: start with top cases by volume
• Identify/match required shoppable service codes with DRGs
• Example: Vaginal deliveries professional code 59400 which is also
shoppable service
5. Outpatient: review service bundles with labs, E&M services
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17. Data Reporting
Prepare for Potential Data Issues
• Chargemaster must be up to date and complete
• Cannot be missing NDCs, units of service for drug codes, etc.
• 835/837 claim data may be incomplete or not available
• Consider payment information not be available to split between
professional/technical services
• Incorporate distinct transaction codes
• Payer contracts may be outdated or not readily available
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18. Using Price Estimator
• Provide estimates for as many of the 70 CMS-specified
shoppable services and as many additional hospital-selected
shoppable services for a combined total of at least 300
• Obtain an estimate of the amount they will be obligated to pay
• Prominently displayed on the hospital’s website; accessible to
public without charge and without having to register or
establish a user account or password
Can PII and/or insurance information be collected?
• Yes, in order to provide real-time personalized out of pocket
price estimates
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• Warning letter sent
to non-compliant
• 90 days to respond
1st Notice
• Warning letter or
• Corrective Action
Plan issued
2nd Notice
• CMS issuance of
monetary penalty
to non-compliant
3rd Notice

20. CMS Ensuring Compliance
• CMS proactively auditing websites and actively reviewing public
complaints
• Daily civil monetary penalty for non-compliance
• $300/day for smaller hospitals with 30 or less beds
• $10/bed/day (not to exceed $5,500) for hospitals count >30
• Full calendar year of non-compliance total penalty would be
$109,500 minimum, maximum $2M
• Hospitals have the right to appeal monetary penalties by requesting
ALJ hearing within 30 days of issuance of penalty
• Issued round of warning letters issued April 2021; 165 sent by
July; 256 sent by end of September
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21. No Surprises Act
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• Bans surprise patient billing for emergency and out of network
services provided at in-network facilities
• Patient cost sharing cannot be higher than in-network
• Creates a consent process
• Providers required to inform the public
• OON payments based on median in-network rate 2019 - forward

22. What Qualifies as Surprise Billing
Patient unknowingly receives care by an out
of network provider at an in-network facility
or emergency
Includes:
• ED visits at out of network facility
• Certain services & post stabilization services
• Air ambulance services provided by OON
provider
• Out of network provider at in-network
provider. Example anesthesiologist, lab
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23. • Nearly all private health plans affected
• ED and Air Ambulance services processed in-network
• Out of network reimbursed at “qualifying rate” without prior
authorization
• Interim payment or notice of denial 30 days receipt of ‘clean
claim’. Plan can extend 15 days for additional information
• Routine denials not allowed
• Payment made to provider, not to patient/subscriber
Payor Provisions
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24. Advanced EOB
Applicable for in and out of network services
Upon member request with 1 day turn around time
Facility is participating provider (INN) and contract rate for item or service
Description on how to find information on INN providers
Good faith estimates of provider billed charges, insurance allowable, cost-share
responsibility, current standing on deductibles and OOP max
Any applicable disclaimers
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25. Member ID Cards
Plan years beginning January 1st, 2022
In-network (INN) deductible
Out-of-network (OON) deductible
Out of pocket maximum limit
Member assistance contact number and website URL
Where to find INN providers
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26. • Provide notice to consumers: single page
notice and website
• Consent can be utilized (not required) for
non-emergent out of network services
• Implement workflow to ensure validity of
patient cost share
Provider Provisions
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27. Reimbursement Timeline
30 days
Payer pay or
deny claim
30 Day open
negotiation
4 days
Provider or
payer can
initiate
federal
Independent
Dispute
Resolution
(IDR) process
10 days
Both parties
submit offer
Dollar
amount and
% of QPA
Provider type
& facility
size
Coverage
area, fully
insured/self
insured
30 days
IDR Review
and decide
payment
amount
Written
notification;
include
rationale and
detailed
explanation
90 day
Cool off
period
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28. Qualifying Payment Amount
• Median in-network rate for 2019 trending forward
• IDR factors in:
• Provider level of training or experience, quality and outcomes
measurements; teaching status, case mix, scope of facility services
• Type of contract, insurance market, geographical region, if good faith
efforts – or lack thereof – to join network, prior contract rates – last 4
years
• Patient acuity and complexity of services provided
• Cannot consider usual and customary charge, billed charge or
reimbursement rates of public payers (Medicare, Medicaid,
Tricare)
• Only deviate if there is credible information presented
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29. Keys to Survival
Focus
Be steadfast with
payment offers
and negotiations
• Out of network
payors are persistent
• Hoping providers
will give up and
accept payment
Optimize
Consider building
specialized team
• Focus on experience;
provide tools and
regular training
• Develop robust
response workflow
• Transparent reporting
• IDRs can be handled in
bundles
Report
Track comparable
data
• Aggregate data and
results
• Allowables by payer,
appeal levels,
success rate
Implement
Implement robust
font-end consent
form process
• Educate front-end
staff on new cards
and what OON
means
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