CMS is enforcing its rule with penalties.
The Centers for Medicare & Medicaid Services (CMS) is focusing new funding and efforts on hospital price transparency compliance enforcement. At the same time, state-level agencies like the Texas Health and Human Services Commission (HHSC) have begun issuing material violation notices and penalties for non-compliance.
In September 2022, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) added CMS Hospital Price Transparency oversight to their Work Plan. The Work Plan includes a review of the audit controls in place at CMS to ensure that mandated hospital price transparency information has been made publicly available, as required by law.
“To evaluate CMS’s monitoring and enforcement of the hospital price transparency rule, we will review the controls in place at CMS and statistically sample hospitals to determine whether CMS’s controls are sufficient to ensure that hospital pricing information is readily available to patients as required by Federal law,” the agency said.
If the hospitals reviewed do not comply with CMS’s rule for publicly posting their pricing and rate information, OIG will contact the hospitals to assess the reason for noncompliance and determine any imposed consequences.
In addition to the OIG Work Plan, HHSC recently awarded a contract to an outside consulting agency for an initiative titled “Hospital Price Transparency Enforcement and Compliance.” The start date of the award is July 7, 2022, with enforcement work continuing into 2027.
Compliance with the federal price transparency mandate has been proceeding at a crawl, as many hospitals claim that the overwhelming administrative burden and lack of IT and revenue cycle staff make meeting the requirements difficult. There is also the difficulty and complexity associated with gathering the correct data sources, extracting the information, and building the technical resources required to meet the rule.
There are two core mandated formats that hospitals must produce to meet the price transparency mandate. First, and most importantly, there is the comprehensive machine-readable file of all items and services. This format must include pricing information for all of a hospital’s items and services, and all commercial payor-negotiated rates, down to the plan level.
In addition to the machine-readable file, hospitals must also produce a display of “shoppable” services, providing a user-friendly experience for patients to filter through pricing information. This format requires a total of 300 services, 70 of which have been pre-defined by CMS. The consumer-friendly experience must be free of barriers, such as requiring registration, login, or insurance information to gain access to hospital pricing.
Hospitals can benefit by creating the machine-readable file in a modern and API-ready data format (like JSON or XML) to prepare for the next phase of requirements, and to utilize their own data points within other internal software programs. Unlike the hospital price transparency rule, CMS has invested in the development of a standardized schema for the Transparency in Coverage rule, which is a similar rule applicable to the insurance companies.
An assumption can be made that a similar schema will soon apply to the hospital price transparency machine-readable files to address inconsistencies with the data formats due to a looser set of restrictions in the rule.
About the Author:
Jory Hatton is CEO of ClaraPrice, Inc., a hospital compliance organization based in Austin, Texas. ClaraPrice provides hospitals with innovative software solutions to offload the administrative burden of internal management of CMS Price Transparency and No Surprises Act compliance. After serving in roles both as Vice President of Engineering and Product, Jory co-founded ClaraPrice to accelerate innovation in healthcare IT and patient access.
Contact the Author: jory@claraprice.com
Federal officials announced this week that one of the nation’s largest health insurers has agreed to pay $117.7 million to resolve fraud allegations. The False
The Centers for Medicare & Medicaid Services’ (CMS’s) $50 billion Rural Health Transformation Program was designed by the Trump Administration to reshape healthcare delivery in
Please log in to your account to comment on this article.
Uncover essential coding insights with nationally recognized coding authority Kay Piper, RHIA, CDIP, CCS. Through ICD10monitor’s interactive, on‑demand webcast series, Kay walks you through the AHA’s 2026 ICD‑10‑CM/PCS Quarterly Coding Clinics, translating each update into practical, easy‑to‑apply guidance designed to sharpen precision, ensure compliance, and strengthen day‑to‑day decision‑making. Available shortly after each official release.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s fourth quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s third quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s second quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
