Beyond Compliance with Hospital Price Transparency

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Beyond Compliance with Hospital Price Transparency

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Beyond Compliance with Hospital Price Transparency With Host Kevin Chmura, CEO of Panacea Healthcare Solutions and Guest Govi Goyal, President, Financial Services of Panacea Healthcare Solutions In this episode of Beyond the Bottom Line, Kevin Chmura is joined by Panacea’s President of Financial Services, Govi Goyal, to discuss the recent changes in the latest chapter in Hospital Price Transparency. Govi presents his thoughts regarding the latest price transparency requirements, with a heavy emphasis on machine-readable file, which received a decent amount of changes since last year. He will also touch on the events that led us to today’s landscape, while also exploring compliance pitfalls to be aware of. Episode transcript available below. Kevin Chmura Hi, and welcome to this episode of Panacea’s podcast, Beyond the Bottom Line. Let’s talk healthcare, finance, revenue cycle and compliance. I’m your host, Kevin Shimura, CEO of Panacea Healthcare Solutions. Today we’re welcoming back Govi Goyal, our President of the Financial Services Division at Panacea, to talk about recent changes in the latest chapter in hospital price transparency. Govi, welcome back. Govi Goyal Thank you. Kevin Chmura So Govi, we’ve done a bunch of these together and as usual you maintain your position as a leading national thought leader on the topic of price transparencies. So rather than maybe bringing, you know, dragging you through and asking you a series of questions, maybe I’ll just open up the floor to you. I think people want to hear what you’re thinking about. Especially as it comes to the new machine-readable file requirements. You know, we had an awkward series of events that got us to where we are today. Maybe you could touch on that and maybe just talk about some compliance pitfalls. That you can see. And so rather than me getting in your way, I’ll turn it over to you and let you take it from here. Govi Goyal Yeah, absolutely. I think awkward is a good way to describe it. The timing is really good though. It’s another year. So we’ve got another year of new price transparency requirements. This time there’s not any changes to the consumer display or patient estimation system, but there’s certainly a decent amount of changes that are happening with the machinable file, which has really been a work in progress, I’d say over these last few years, but there’s been significant activity within the last year. So, in just a few weeks here, April 1st, CMS will begin enforcement of the new requirements that were laid out. In both the proposed and final rule for 2026. Technically these are effective January 1st, we’ve got a little bit of grace period which I think hospitals are taking advantage of it. So on the technical side of things, what we’re seeing is that CMS is really getting. What’s getting rid of the replacing the estimated, the current estimate allowed amounts with four new allowed amount fields. And these fields are the median allowed amount, the 10th percentile, 90th percentile and then the count of allowed amounts. And so I think it’s really important to kind of understand this part there and you know why. What does this really mean and why is this happening? So as a kind of a refresher here, estimated allowed amounts by definition refers to the historical average payment that a hospital received for that given payer or plan and for that for that billing code. And it’s really applicable when you may not have a standard negotiate rate or you have a standard negotiate rate. But then that could be varied by other factors. So for example, you’re getting paid on a percentage charge on a DRG. We know that the gross charges could vary from patient to patient. There’s not a standard negotiated rate. So CMS came up with the estimated allowed amount, which is basically a second field for a negotiated rate when there is no standard. Or let’s say you have a scenario where you’re a hospital, you’re getting paid on a case rate for a given surgical procedure, but then there’s also the opportunity to get paid an additional amount if it’s a high dollar claim in the in the concept of stop lossless or lessor of, so that whole concept is not changing. CMS is not changing the qualifications, how you qualify a line item that would need in this case going forward for 2026 in April, now a median allowed amount. Really what’s changing here is the calculation itself. So instead of looking at a historical average, we’re now CMS is now asking hospitals to get to the median, the 10th and the 90th percentile and then also include the count of allowed amounts. So the qualification process same, the calculations are changing and I think you hit the nail on the head there, Kevin. We have to kind of go back in time. We got to get in our time machine here. We don’t have to go too far back, but if we go back about a year ago and think about the executive order. That’s really where...

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