At the end of 2019 CMS issued two Federal Register entries. One FR entry was the extension of the 2020 OPPS update and the other was a separate FR entry that was published jointly for CMS, the Treasury Department and the Internal Revenue Service (IRS). The second FR entry was devoted to group health plans making charge and payment information available. The first FR entry was devoted to hospitals of all types making charges and payments public.
While there will probably be significant lawsuits, the bottom-line is that hospitals must prepare to make their charges public and then to meet a number of significant requirements. Fortunately CMS has decided to set the implementation on January 1, 2021 although there may be further delays and changes to the rule over the coming year.
- What are hospitals?
- Why are hospital charges and pricing so controversial?
- How did hospital prices become inflated?
- What are items and services?
- What is this ‘transparent pricing’?
- How do group plans become involved in transparent pricing?
- What are charges and how do they relate to payments?
- What are shoppable services?
- What steps must a hospital take in order to meet the requirements?
- What is machine-readable format?
- What are the compliance issues?
- Is there an appeal process?
- To understand the scope of application for transparent pricing.
- To review the various definitions surrounding transparent pricing.
- To understand the relationship between charges and payments.
- To appreciate was it meant by items and services.
- To appreciate what constitutes a shoppable services.
- To understand what Medicare beneficiaries and other patients gain with transparent pricing.
- To review the rules, regulations and requirements for hospitals to meet the transparency requirements.
- To appreciate how group health plans become involved in providing patients with information so that informed decision can be made.
- To understand the compliance issues for transparent pricing.
- To appreciate the appeals process for meeting transparent pricing requirements.
- To appreciate that legal action surrounding transparent pricing should be anticipated.
- Overview of Developing Chargemaster Pricing and Charges
- The Need For Changes
- Charge Formulas and Mark-Up Formulas
- Strategies for Adjusting Pricing
- Transparent Pricing
- Strategic Pricing
- Geographic Pricing
- Pricing Disparities Among Hospitals
- Transparent Pricing Requirements
- Applicable Scope for Transparent Pricing
- Charges versus Payments
- Cost-Sharing Information
- Items and Services-
- Shoppable Events
- Group Health Plan Involvement
- Physicians versus Hospitals
- Disclosure of Information
- Hospitals and Shoppable Events
- Group Health Plans Payments and Costs
- Machine Readable Format
- Internet Availability of Information
- Compliance with Transparent Rules and Regulations
- Auditing Activities
- Civil Monetary Penalties (CMPs)
- Appeals Process
- Possible Litigation and Impact on Preparing For Transparent Pricing
- Chargemaster Coordinator Action Step
- Outpatient Staff
- Nursing Staff
- Outpatient Departmental Managers
- Nurse Auditors
- ED Nursing Staff
- Provider-Based Clinic Nursing Staff
- Coding Personnel
- Coding, Billing and Claims Transaction Personnel
- Internal Auditing Personnel
- Financial Analysts
- Revenue Cycle Specialists
- Compliance Personnel
- Cost Accounting Personnel
- Chargemaster Coordinators
- Cost Reporting Personnel
- Other Interested Personnel
About the Presenter:
Duane C. Abbey, PhD, CFP, is a management consultant and president of Abbey & Abbey Consultants, Inc., a consulting firm specializing in healthcare and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. Dr. Abbey works extensively in all areas relating to compliance reviews, coding, billing and reimbursement with particular emphasis on the chargemaster and outpatient payment. His consulting activities include hospitals and physicians based clinics.
In addition to his consulting practice, Dr. Abbey also teaches workshops and makes presentations on a regular basis. He has taught at the University level and speaks nationally. He is a regular presenter for hospital associations, medical societies, Boards of Trustees and various other organizations and groups. In addition, professional societies such as HFMA use Dr. Abbey’s services to present seminars and workshops.
Dr. Abbey is a nationally recognized expert in payment systems. A special area of expertise includes APGs/APCs. He is recognized as the leading expert in the nation in APGs/APCs by the thousands who have attended his seminars, read his publications and/or contracted for his services. Attendees at these seminars over the years have included personnel from hospitals, clinics, integrated delivery systems and multiple consulting firms.
Dr. Abbey is also the author of numerous articles and books including: Compliance for Coding, Billing & Reimbursement, Outpatient Services: Designing, Organizing & Managing Outpatient Resources, ChargeMaster: Review Strategies for Improved Billing and Reimbursement, Ambulatory Patient Group Operations Manual, published by McGraw-Hill and Non-Physician Providers: Guide to Coding, Billing & Reimbursement, Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance, and Emergency Department Coding & Billing: A Guide to Reimbursement & Compliance published.
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