American Hospital Association urges CMS to expand law enforcement discretion without surprises


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The American Hospital Association has urged the Centers for Medicare and Medicaid Services to extend enforcement discretion to the No Surprises Act’s regulatory requirement that health care providers exchange certain information to create a good faith estimate. for uninsured and self-paid patients – until the agency identifies, and providers can implement a standard, automated way to exchange the information.

“In the Interim Final Rule implementing this policy, CMS notes that it is exercising enforcement discretion until January 1, 2023, as it may take time for vendors and facilities to “develop systems and processes to receive and provide required information”, “AHA wrote. “We agree that the development and implementation of the solution will take time and cannot be completed effectively without further guidance from CMS identifying a standard technical solution that can be implemented by all vendors.”

In the federal price transparency rule that went into effect on January 1, 2021, hospitals were instructed to publish all of their prices online in clear and easily accessible formats. A KLAS survey released in April indicated that hospitals generally support such regulations as a step toward consumerizing healthcare.

But concerns about the accuracy of pricing and whether patients would fully understand the complexity of the costs of the procedures have been heightened by fears from smaller hospitals that consumers will be drawn to larger healthcare organizations which, due to of their size, could offer lower fares.

One of the AHA’s primary concerns is that there is currently no method for unaffiliated vendors to share or receive Good Faith Estimates with a vendor or convening facility in an automated manner. To share this information, billing systems should be able to request and transmit billing rates, discounts and other information necessary for good faith ratings between providers/facilities.

That’s not something practice management systems typically can do, the AHA said, since billing information has traditionally been sent to health insurers and clearinghouses, not other providers. .

“Due to the lack of automated solutions currently available, this process would require significant manual effort on the part of providers, which would undoubtedly prevent the calling provider from meeting the short legal deadlines for providing good faith estimates to patients and could also lead to unintended errors,” the AHA wrote.

AHA requested an extension of execution discretion until a technical solution was found and implemented.


Without an automated standard, the AHA said, providers would have to individually determine how to transmit information. This in turn could lead to variances across the industry, especially given the differences in size and technical sophistication between co-suppliers and facilities. Navigating a non-standardized process, according to the AHA, would increase the administrative burden on providers.

To help work toward a standard solution, the AHA said it is partnering with the American Medical Association, the Medical Group Management Association, and HL7 to create a working group to discuss potential technical solutions for share and receive critical information between suppliers. The group will be made up of vendors and vendors familiar with vendor systems.


In a February survey by patientsrightsadvocateorg, data showed that to date only 1.3% of 1,000 hospitals comply with the price transparency rule.

About 38% of the hospitals surveyed posted a sufficient number of negotiated rates, but more than half failed to meet other criteria in the rule, such as the rates for each designated insurer and plan. At the same time, only 0.5% of hospitals in the country’s three largest hospital systems – HCA Healthcare, CommonSpirit Health and Ascension – were compliant.

The results were consistent with earlier findings, published in June 2021 in the Journal of the American Medical Association and the American Journal of Managed Care, showing that most hospitals are not following the price transparency rule.

The rule established penalties for non-compliance at $300 per day for hospitals with less than 30 beds and $10 per bed per day for hospitals with 31 beds or more, up to a maximum daily penalty of 5 $500.

The AHA argued that disclosing privately negotiated rates does nothing to help patients understand what they will actually pay for the treatment. It also accelerates anticompetitive behavior by commercial health insurers and hampers innovations in value-based care delivery, the AHA said.

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