Price Transparency MRF Requirements Download Verify compliance with the machine-readable files requirementsBy Caroline Znaniec, MBA, MS-HCA, CRIP, CRCR, and Joe O’Malley, CHCThe Hospital Price Transparency Rule was implemented on January 1, 2021, and codified in the Code of Federal Regulations (Title 45, Subtitle A, Subchapter E, Part 180). CMS has finalised new changes to increase standardisation of the machine-readable files (MRF) to help deliver on the promise of hospital price transparency. Ensure that your hospital complies to enhance the public’s ability to access and aggregate information and streamline CMS’s ability to enforce the requirements.*Reprinted with permission from New Perspectives, Journal of the Association of Healthcare Internal Auditors, Inc. Volume 43/ Number 2, 2024. Download Topics Risk Management and Regulatory Compliance Industries Healthcare and Life Sciences In response to industry members’ requests for standardisation in reporting, CMS developed a template and encoding requirements for the price transparency data elements. The CY2024 Outpatient Prospective Payment System (CY2024 Final Rule) published November 22, 2023, It’s 2024. Do Patients Know Where Your MRF Is? Verify compliance with the machine-readable files requirements By Caroline Znaniec, MBA, MS-HCA, CRIP, CRCR, and Joe O’Malley, CHC FEATURE provides guidance and related implementation (compliance) dates specific to the accessibility, format and structure, and content of the MRF. Exhibit 1 summarises the compliance dates, which vary by requirement and range from January of 2024 through January of 2025.Exhibit 1 – Summary of compliance datesRequirementRegulationImplementation (compliance) dateMRF InformationMRF Date45 CFR 180.50(b)(2)(i)(B)July 1, 2024CMS Template Version45 CFR 180.50(b)(2)(i)(B)July 1, 2024Hospital InformationHospital Name45 CFR 180.50(b)(2)(i)(A)July 1, 2024Hospital Location(s)45 CFR 180.50(b)(2)(i)(A)July 1, 2024Hospital Address(es)45 CFR 180.50(b)(2)(i)(A)July 1, 2024Hospital Licensure Information45 CFR 180.50(b)(2)(i)(A)July 1, 2024Standard chargesGross Charge45 CFR 180.50(b)(2)(ii)July 1, 2024Discounted Cash45 CFR 180.50(b)(2)(ii)July 1, 2024Payer Name45 CFR 180.50(b)(2)(ii)(A)July 1, 2024Plan Name45 CFR 180.50(b)(2)(ii)(A)July 1, 2024Standard Charge Method45 CFR 180.50(b)(2)(ii)(B)July 1, 2024Payer-Specific Negotiated Charge – Dollar Amount45 CFR 180.50(b)(2)(ii)(C)July 1, 2024Payer-Specific Negotiated Charge – Percentage45 CFR 180.50(b)(2)(ii)(C)July 1, 2024Payer-Specific Negotiated Charge – Algorithm45 CFR 180.50(b)(2)(ii)(C)July 1, 2024Estimated Allowed Amount45 CFR 180.50(b)(2)(ii)(C)January 1, 2025De-identified Minimum Negotiated Charge45 CFR 180.50(b)(2)(ii)July 1, 2024De-identified Maximum Negotiated Charge45 CFR 180.50(b)(2)(ii)July 1, 2024Item and service informationGeneral Description45 CFR 180.50(b)(2)(iii)(A)July 1, 2024Setting45 CFR 180.50(b)(2)(iii)(B)July 1, 2024Drug Unit of Measurement45 CFR 180.50(b)(2)(iii)(C)January 1, 2025Drug Type of Measurement45 CFR 180.50 (b)(2)(iii)(C)January 1, 2025Coding informationBilling/Accounting Code45 CFR 180.50(b)(2)(iv)(A)July 1, 2024Code Type45 CFR 180.50(b)(2)(iv)(B)July 1, 2024Modifiers45 CFR 180.50(b)(2)(iv)(C)January 1, 2025Other new hospital price transparency requirementsGood faith effort45 CFR 180.50(a)(3)(i)January 1, 2024Affirmation in the MRF45 CFR 180.50(a)(3)(ii)July 1, 2024.txt file45 CFR 180.50(d)(6)(i)January 1, 2024Footer link45 CFR 180.50(d)(6)(ii)January 1, 2024 AccessibilityAs of January 1, 2024, a hospital must ensure that its MRF is easily accessible by both the public and by CMS for automated auditing. The new requirements include a .txt file and website footer. A hospital’s good faith effort in providing access to its MRF is demonstrated through meeting these requirements together with the publishing of the MRF itself. .txt fileThe .txt file must be placed in the root folder of the website domain that hosts the MRF. The .txt file is a document that provides information specific to the hospital location name, source page URL that hosts the MRF, a direct link to the MRF, and designated point of contact information. To assist hospitals in generating the MRF, CMS provides instructions and a generator tool for document output.Exhibit 2 – Example .txt file output Image While a health system may post multiple MRFs on its source page, all locations should be included in the single .txt file document.Exhibit 3 − Example .txt file output with multiple locations Image When multiple locations (e.g., acute care hospital, stand-alone emergency center) share an MRF, a separate entry must be included in the output by location.Exhibit 4 − Example .txt file output for shared MRF Image Where a hospital uses a vendor to host its MRF, the .txt file should indicate the vendor’s source page URL and the MRF URL established by the vendor. The point of contact should reflect the person or team of people that can answer questions regarding the publicly available MRF information. Website footerThe hospital must provide a link in the footer of its website that is labeled exactly: “Price Transparency.” Other variations, such as “Pricing Transparency” or “Hospital Price Transparency,” are not acceptable. The footer must link directly to the publicly available webpage that hosts the link to the MRF.Format and structureAs of July 1, 2024, hospital MRFs must conform to a CMS template layout. The compliance date applies to all hospitals, regardless of their use of prior voluntary templates or last annual update date. For example, if a hospital last updated its MRF in December of 2023, it must comply with the CMS template by July 1, 2024. Hospitals must continue to provide annual updates up to and after the required compliance dates.CMS has published the template layout in three formats: CSV “Tall,” CVS “Wide,” and JSON. Hospitals may choose the format for publishing their charges. Within each format, CMS has adopted established standards and industry norms. The requirements include valid types by data element, such as string, date, Enum, numeric and Boolean. Values encoded incorrectly will generate a compliance deficiency. With each template format, CMS provides a README file that lists the valid types by data element, along with additional instructions.ContentThe content for the CMS MRF template resembles much of what has been in place since 2021. The content includes providing item and service descriptions, billing identifiers and standard charges, including gross and discounted cash prices and de-identified minimum and maximum charges. Under the CY2024 Final Rule, additional data elements are included to improve the public’s understanding of hospital provider and payer charge methodologies.Steps for publicising your hospital charges using a required CMS template layoutIdentify your hospital and each hospital location that must make available its list of standard charges.Identify each standard charge your hospital has established and its corresponding item or service.Select a required CMS template.Gather and encode your standard charge information in the CMS template.Affirm the accuracy and completeness of your file.Name your MRF according to the CMS naming convention.Validate that you have encoded your data correctly within the CMS template.Post your machine-readable file prominently on a publicly available website.Add the .txt file and footer link.Update your hospital’s MRF annually.Source: https://www.cms.gov/files/document/steps-machine-readable-file.pdf The data elements provide information that contextualise the standard charges of the hospital. CMS categorises the data elements into five groups:MRF InformationHospital InformationStandard chargesItem and service informationCoding informationExhibit 5 summarises the new data elements as of July 1, 2024. An asterisk indicates a compliance date of January 1, 2025.Exhibit 5 – New data elementsCategoryNew data element as of July 1, 2024 (Asterisk indicates required as of January 1, 2025)Definition and considerations1. MRF informationMRF dateProvide the calendar date of the last file update.CMS template versionCMS template version 2.0.0 is current as of May 2024.Affirmation statementInclude a pre-populated statement, written and required by CMS, with a value encoded of “True” or “False” to confirm to the best of the hospital’s knowledge that the information provided is true, accurate and complete as of the date of the MRF.2. Hospital informationHospital nameProvide the legal name of the hospital.Hospital location(s)Include the unique name of the hospital location(s), absent acronyms.More than one hospital location is included when >1 location is included in the MRF. For example, under a single license a hospital and standalone emergency center share the same standard charges.Hospital address(es)Disclose the geographic address of the corresponding locations.Hospital licensure informationDisclose the hospital license and state/territory abbreviation. If the hospital does not have a license (e.g., state-owned hospitals), the field can be left blank. Hospitals without a license number, but with a registry number, may include the registry number as an option, but not required.3. Standard Charges (Additional data elements including gross charge, discounted cash price, de-identified minimum and maximum charges remain unchanged and are required in the CMS template.)Standard charge methodProvide the method used to establish the payer-specific negotiated charge.Valid values include:Case rateFee schedulePer diemPercent of total billed chargesOtherPayer-specific negotiated charge – dollar amountDisclose the charge that a hospital has negotiated with a third-party payer for the corresponding item or service.The value is expressed as a dollar amount without dollar signs or cents when the cents are “00.”Payer-specific negotiated charge – percentageComplete this when a payer-specific negotiated charge has been established as a percentage and no dollar amount can be calculated. For example, when the negotiated charge is based on the aggregation of charges that may vary by patient (e.g., inpatient stay, surgical procedure).The percentage is provided as a numeric representation and not as a decimal. For example, 65.5 percent is to be entered as 65.5 and not .655.An estimated allowed amount must also be calculated when this type of negotiated charge is encoded.Payer-specific negotiated charge – algorithmDisclose the expressed algorithm that the hospital has negotiated. For example, the adjusted base payment rate indicated in the standard charge/negotiated dollar data element may be further adjusted for additional factors including transfers and outliers.An estimated allowed amount must also be calculated when this type of negotiated charge is encoded.Estimated allowed amount*Provide the average dollar amount that the hospital has historically received from a third-party payer for an item or service.If historic claims history is insufficient to derive the estimated allowed amount, the hospital should encode 999999999 (nine 9s) in the data element value.Additional generic notesUse free text data to explain any of the data, including, for example, blanks due to no applicable data, charity care policies, or other contextual information that aids in the understanding of the standard charges.Additional payer-specific notesUse free text data to explain data in the file that is related to a payer-specific negotiated charge.4. Item and service information (The General Description data element remains unchanged from prior requirements and is required in the CMS template.)SettingProvide Information that indicates the setting of the item or service.Valid values include:InpatientOutpatientBothDrug unit of measure*Indicate the unit value that corresponds to the established standard charge.For example, an 81mg aspirin unit of measure would be indicated as 1.Drug type of measurement*Disclose the measurement type that corresponds to the established standard charge for drugs as defined by either the National Drug Code or the National Council for Prescription Drug programmes. The measurement aligns to volume measurement and may not correspond with HCPCS (e.g., J-Code) billable units.Valid values include:GM or GR (grams)ME (milligrams)ML (milliliters)UN (unit)F2 (international unit)EA (each)For example, an 81mg aspirin type of measurement would be indicated as UN.5. Coding informationBilling/accounting codeThe code(s) are used by the hospital for purposes of billing or accounting for the item or service.Billing/accounting code greater than one may be associated with an item or service. For example, a payer may require the combination of a revenue code and CPT code for reimbursement.Code typeto indicate the type of code displayed. Valid values include, but are not limited to:CPTHCPCSNDCMS-DRGRCModifiers*Provide any modifier(s) that may change the standard charge that corresponds to hospital items or services. Payment modifiers may include:Prolonged service−22Bilateral procedure−50Reduced service−52Staged procedure−58 CMS has provided examples of how to complete the CMS template based on common scenarios and continues to add to the scenarios as providers reach out with questions and request further guidance.CMS scenario examplesExhibits 6–10 provide examples of CMS scenarios. The data has been transposed from CSV Tall format for illustrative purposes and includes only those data elements with values.Exhibit 6 – Case rate based on a MS-DRG algorithmCategoryDescriptiondescriptionMajor hip and knee joint replacement or reattachment of lower extremity without mcccode|1470code|1|typeMS-DRGcode|2175869code|2|typeLOCALsettinginpatientpayer_namePlatform Health Insuranceplan_namePPOstandard_charge|negotiated_dollar20000standard _charge|negotiated_algorithmThe adjusted base payment rate indicated in the standard charge or negotiated dollar data element may be further adjusted for additional factors including transfers and outliers.estimated_amount22243.34standard_charge|methodologycase ratestandard_charge|min20000standard_charge|max20000 Exhibit 7 – Percent of total billed chargesCategoryDescriptiondescriptionMajor hip and knee joint replacement or reattachment of lower extremity without mcccode|1470code|1|typeMS-DRGcode|2175869code|2|typeLOCALsettinginpatientpayer_nameRegion Health Insuranceplan_nameHMOstandard_charge|negotiated_percentage50estimated_amount23145.98standard_charge|methodologyPercent of total billed chargesstandard_charge|min20000standard_charge|max20000 Exhibit 8 – Fee schedule: Standard charge is a percent of a common fee schedule and the standard charge dollar amount can be calculatedCategoryDescriptiondescriptionEvaluation of hearing function to determine candidacy for, or postoperative status of, surgically implanted hearing device; first hourcode|192626code|1|typeCPTcode|1|typeoutpatientstandard_charge|gross150standard_charge|discounted_cash125payer_namePlatform Health Insuranceplan_namePPOstandard_charge|negotiated_dollar98.98standard_charge|methodologyfee schedulestandard_charge|min98.98standard_charge|max98.98additional_generic_notes110% of the Medicare fee schedule Exhibit 9 – Fee schedule where the standard charge is a percent of a common fee schedule, and the standard charge dollar amount cannot be calculatedCategoryDescriptiondescriptionEvaluation of hearing function to determine candidacy for, or postoperative status of, surgically implanted hearing device; first hourcode|192626code|1|typeCPTsettingoutpatientstandard_charge|gross150standard_charge|discounted_cash125payer_nameRegion Health Insuranceplan_nameHMOstandard_charge|negotiated_percentage115estimated_amount105.34standard_charge|methodologyfee schedulestandard_charge|min98.98standard_charge|max98.98additional_generic_notes115% of the state's workers' compensation amount Exhibit 10 – Per diem where the standard charges are for a length of stay of 1– 3 daysCategoryDescriptiondescriptionBehavioral health; residential (hospital residential treatment programme), without room and board, per diem, days 1–3code|1H0017code|1|typeHCPCSsettinginpatientstandard_charge|gross2500standard_charge|discounted_cash2250payer_nameRegion Health Insuranceplan_nameHMOstandard_charge|negotiated_dollar2000standard_charge|methodologyper diemstandard_charge|min2000standard_charge|max2000 Exhibit 11 – Per diem where the standard charges are for a length of stay of 4–5 daysCategoryDescriptiondescriptionBehavioral health; residential (hospital residential treatment programme), without room and board, per diem, days 4–5code|1H0017code|1|typeHCPCSsettinginpatientstandard_charge|gross2500standard_charge|discounted_cash2250payer_nameRegion Health Insuranceplan_nameHMOstandard_charge|negotiated_dollar1800standard_charge|methodologyper diemstandard_charge|min1800standard_charge|max1800standard_charge|max98.98 Noncompliance risks are high for hospitals that do not meet accessibility requirements and publish an MRF in the required format.Audit programme considerationsHospitals at the highest risk of noncompliance include those that do not meet accessibility requirements or do not publish a machine-readable file in the required CMS template format. In establishing your audit work programme for hospital price transparency, you can leverage CMS’ resources (see sidebar) to understand the full requirements and to align your testing with the highest risks. Further audit steps should include interviews of those stakeholders responsible for both compiling the MRF content and formatting to the new required structure.Testing should include a comparison to payer contract and reimbursement terms, as well as reconciliation of the chargemaster and other modules that may house charge detail (e.g., room and board tables, pharmacy formularies, supply item masters).Testing provides confidence in affirming to CMS that “To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.”ResourcesCMS−ResourcesHospital Price Transparency Fact SheetHospital Price Transparency: Using a CMS Template Layout to Encode Hospital Standard Charge InformationTechnical Implementation GuideHealthcare Financial Management Association − CMS finalises enhanced hospital price transparency requirements for 2024ConclusionDespite challenges and resistance by hospitals, CMS has doubled down on requirements to make MRFs easier to find and use. By working toward pricing transparency compliance, hospitals reduce the risk of monetary fines, public scrutiny and reputational damage, while potentially uncovering charge capture opportunities and increasing the quality and efficiency of their revenue cycle processes. Help your hospitals gain these advantages. I would rather work with five people who really believe in what they are doing ... than five hundred who can't see the point. Patrick Dixon, business consultant
