May 22, 2025 Guidance
On May 22nd, CMS released a documented titled “Updated Hospital Price Transparency Guidance Implementing the President’s Executive Order 'Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information.'”
Updated MRF Formatting
In order to build MRFs compliant with the updated guidance, Turquoise has rerun all files to ensure they are formatted to be compliant with the new guidance. You can read the updated guidance here. Our MRF generation team has made the following changes to our file creation approach:
Reimbursement Method Changes
Compliant approach prior to May 22: Rates could be reported in an MRF categorized by a reimbursement method of case rate or per diem that were displayed as algorithms.
Updated approach to comply with new Guidance: Any algorithms must be posted with a reimbursement method of "Other," except if the rate is a percent of an unavailable fee schedule. In that event, we input the rate into the payer-specific negotiated percentage field.
Estimated Allowed Amount (EAA) Changes
Compliant approach prior to May 22: EAAs were only included in a file if there were at least 10 instances of payment for the specific service paid by the applicable payer/plan combination in claims data.
Updated approach to comply with new Guidance: EAAs are included in the file if there is at least 1 instance of payment for the specific service paid by the applicable payer/plan combination in claims data. The corresponding notes data element is also updated to state that there was “one or more instances of the item or service in the 12 months prior to posting the file.”
Compliant approach prior to May 22: Turquoise used at least 6 months of claims and remittance data (835/837s specifically) to calculate EAAs.
Updated approach to comply with new Guidance: Turquoise uses claims data from the last 12 months prior to the publish date of the file. If a current contract became effective within the last 12 months, the claims data used to calculate EAA for that payer/plan will be further limited to service dates within the current contract effective window.
Compliant approach prior to May 22: Using the EAA field, rates could be reported as 999999999 in the absence of sufficient claims volume for a specific item or service.
Updated approach to comply with new Guidance: When insufficient claims volume exists to calculate the EAA, the MRF no longer contains 999999999. Turquoise reports the EAA as the average rate for the specific service across all payers and plans. The corresponding notes data element is also updated to state that there were “zero instances of the item or service in the 12 months prior to posting the file.”
Quality Assurance Measures
We continue to run all files through the CMS validator tool to ensure that our files are compliant with all existing requirements for MRF generation as defined by previous final rules, FAQs, and additional guidance. You can learn more about our approach by reading through the additional tabs on this webpage.
Updated about 1 month ago