As a former RAC Auditor (HealthDataInsights Region D), I have some insights on how CMS is using their adjudicated claims to identify hospitals that are violating the required elements in the machine-readable file.
In particular, the new rule requires a hospital to display the FULL charge for a packaged service (e.g., Outpatient Surgery or Inpatient DRG). In a recent interview, I described this as providing the total charge for a cheeseburger, instead of listing the component charges: lettuce, tomatoes, pickles, meat, buns, ketchup, mayonnaise, mustard, onions... This is the intention of the new rule as most patients can not piece together the line-item components that are associated with a packaged service. Here's the actual language in the Federal Register that makes it crystal clear that the charge includes all of the customary ancillary services:
This is a real example (hospital name not shown) of how CMS audits the data.
STEP 1 - CMS Observes Hospital Listing a Colonoscopy Charge as $4,645 for CPT 45378:
STEP 2 - CMS Refers to Its Adjudicated Outpatient Claims Database to Compare the Charges for this Exact Hospital
In this case, CMS confirms that the line-item charge for CPT 45378 (~$4,600) matches the amount in their adjudicated claims database. However, when analyzing all ancillary charges that occur on this hospitals claims that include CPT 45378, the amount increases to $7,184, factoring ancillary services such as Laboratory, Pharmacy, Operating Room, etc.
At this point, CMS, at its discretion, may send a letter asking this hospital to correct its machine-readable file and consumer displays to reflect the "fully-loaded" charge that includes all ancillaries for packaged services.
If you would like HPS to take a confidential vulnerability assessment of your current machine-readable file, please schedule a free meeting on my private calendar: go.oncehub.com/ricklouie
In most cases, we can correct your machine-readable file within a few weeks and make sure your hospital is 100% compliant with the new price transparency rules.