CMS ‘throwing open the shutters’ to require upfront pricing on radiology services

The Trump administration has finalized a rule that will require hospitals to provide upfront pricing on several imaging studies, or face possible audits or even $300 daily fines.

This slew of changes—aimed at providing more price transparency to consumers—would take effect on Jan. 1, 2021. They’d apply to 13 different “shoppable” radiology services that can be scheduled by a consumer in advance. Those include MRI scans of leg joints, x-rays of the lower back with at least four views, mammography of one or both breasts, and CT imaging of the pelvis with contrast, according to the rule.

The Centers for Medicare & Medicaid Services is giving hospitals extra time to comply, but will eventually have new enforcement measures in its tool box to go after scofflaws. Once the rule takes effect, CMS may monitor, audit, demand corrective action plans and impose $300 daily monetary penalties for those who don’t comply, according to the final rule.

“Under the status quo, healthcare prices are about as clear as mud to patients,” CMS Administrator Seema Verma said in a statement. “We are throwing open the shutters and bringing to light the price of care for American consumers. Kept secret, these prices are simply dollar amounts on a ledger; disclosed, they deliver fuel to the engines of competition among hospitals and insurers,” she added. 

Changes to the Calendar Year 2020 Hospital Outpatient Prospective Payment System come after President Trump signed an executive order in June, demanding action on healthcare price transparency. In addition, the administration also released another proposed rule on Friday, Nov. 15, that demands more openness from health plans.

The final rule will require all U.S. hospitals to provide patients with “clear, accessible” information about standard charges for items and services provided. CMS is requiring all hospitals to make those prices available in a single searchable data file.

Hospitals will be tasked with making public all payer-specific negotiated charges and the amount a hospital is willing to accept in cash from a patient for 70 CMS-specified “shoppable services.” In addition to more than a dozen radiology services, those also include lab tests and bundled services like cesarean delivery. Information also must be posted prominently online, be easily accessible, and detailed in “plain language,” according to the announcement.

In the rule, officials noted that previous studies have found that having access to prospective prices for radiology and lab services changed physicians’ ordering behavior, and helped reduce costs.

You can read the entire 331-page final here, along with a shorter fact sheet about the changes here. The full list of CMS-specified shoppable radiology services includes:

  1. CT scan, head or brain, without contrast
  2. MRI scan of brain before and after contrast
  3. X-ray, lower back, minimum four views
  4. MRI scan of lower spinal canal
  5. CT scan, pelvis, with contrast
  6. MRI scan of leg joint
  7. CT scan of abdomen and pelvis with contrast
  8. Ultrasound of abdomen
  9. Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks), single or first fetus
  10. Ultrasound of pelvis through vagina
  11. Mammography of one breast
  12. Mammography of both breasts
  13. Mammography screening, bilateral