10 things hospital CEOs should know about CMS' OPPS proposed rule

On 7/13/23, CMS dropped a new Proposed Rule with many elements. You can read my take on the themes present within the 57 pages, but if you don’t have that kind of time (I mean, same), here are my top ten highlights of the proposed rule.

If you’d rather listen through these, click on the video below!

1. All elements have a 1/1/24 go-live date, except for one

Should the Proposed Rule become finalized, it will go into effect on 1/1/24. However, there's a 60-day grace period for complying with the new MRF standard template, and that would take effect on 3/1/24.

2. New data elements to track data hygiene

A new machine-readable file (MRF) standard template will be required, and it will include new foundational data elements that make it easier for everyone, third parties (CMS included), and academics to track data hygiene. We'll see things like file version, update date, hospital identifier, address, and name. At the aggregate level, this will make it easier for everyone to have better data hygiene.

3. Easier access to MRFs

The new requirements will also make it easier to access MRFs, both for consumers by having a friendly name in the footer of the website, but also for automation by putting a .txt file that points to MRFs in the root of the website.

4. New columns beyond the original five

There are quite a few newly proposed columns beyond the original five. A few highlights include payer and plan being split out, drugs units and type of measurement. Reimbursement methodology will be explicitly required. Now we'll see the percent of charge, per diem. and a long, long tail of other types of reimbursement. Finally, there's an additional information column that is more of a catch-all. CMS put some aspirational data elements that they'd like hospitals to include, but are not required.

5. Expected Allowed Amounts now required

CMS announced a new data element called the “expected allowed amount” that's meant to be consumer-friendly. This is an average and estimated reimbursement for algorithmic type reimbursement methodologies that are not paid at a straight dollar rate. Lots of potential implications here.

6. Increased accountability for hospitals

Enforcement has been increased tenfold with increased accountability and standard data elements.

Here are a few highlights:

• They want to publish a list of compliance actions, not just the civil monetary penalty, but even actions further upstream of that
• I’m imagining a public naughty list, if you will, of hospitals that don't currently have a compliant file. I assume they'd also publish hospitals that are compliant. So, a data naughty and nice list?
• The ability to contact health system leadership, not just a hospital directly, when CMS suspects that a hospital's file is actually under the responsibility of a larger health system.
• An acknowledgment of receipt when CMS sends a letter about monitoring and assessment.

7. Dollar Amounts vs Estimates and Algorithms

This one is particularly interesting. CMS wants to facilitate a choice for consumers and (I think) the industry between dollar amounts and algorithms. They detail a desire to ensure consumers have the right to go somewhere with a fixed, expected upfront payment versus an algorithmically estimated wider range. There is a lot to decipher here, so I’d recommend listening to my full breakdown.

8. CMS investigates Shoppable Services

CMS is seeking additional information on the consumer-friendly display of shoppable services. They want to dig into how those displays could be more aligned in the hospital price transparency rule with other efforts in Transparency in Coverage and the NSA. They also say there a standard service package library for shoppable services that could be used across all three. I assume there’s more to come here.

9. Good Faith Estimates, Advanced Estimates of Benefits (EOBs), and more still up for consideration

The No Surprises Act, Good Faith Estimates, and Advanced EOBs for insured patients are still under consideration. The timeline is unclear, but good to know given the infrastructure required to deliver these to patients.

10. CMS wants to know how third parties are using MRF data

Lastly, CMS is really interested in how third parties like Turquoise are using the MRF data to develop consumer-friendly search tools and how they intend to do that moving forward. There’s an open comment period (we’re going to post!) and we’re looking forward to seeing what other folks post.

If you’re looking for more information on each of these points, I go into specifics here. Looking for specific guidance? Drop us a line!