On May 22, 2025, the Centers for Medicare & Medicaid Services (CMS) announced updated guidance (“guidance”) concerning the Hospital Price Transparency Rule, which requires hospitals operating in the U.S. to publish a list of standard charges for items and services provided by the hospitals.
The guidance was issued to “further clarify” the regulations in order to “provide more meaningful information for third parties and consumers.” The guidance notes that in the instance of the requirement to list dollar amounts for hospitals’ payer-specific negotiated charges, CMS had observed the practice of listing nine 9s instead, meant for “infrequent scenarios,” was being used “much more frequently than expected.”
In the Guidance, CMS states that “in the interests of providing more comparable and useful data to consumers of the files, hospitals should no longer encode nine 9s.” Instead, in calculating the “estimated allowed amount,” they should “encode the average dollar amount the hospital has received for an item or service, derived from electronic remittance advice transaction data using data from items or services rendered within the 12 months prior to posting the file.” The “estimated allowed amount” is defined as “the average amount that the hospital has historically received from a third-party payer for an item or service.”
More generally, CMS said it expects that “for most contracting scenarios, hospitals’ payer-specific negotiated charges can be expressed as a dollar amount.” It added that a hospital that can derive a dollar amount from a hospital’s payer-specific negotiated charge must encode that value in the “payer-specific negotiated charge: dollar amount” data element in the Machine-Readable File (MRF). This is said to apply ‘in particular’ when there is a known case rate, fee schedule or per diem.
Categories: DATA TRANSPARENCY
Leave a Reply