Proposed rule requests stakeholder feedback on publishing prices negotiated between providers and payers

March 13, 2019
Medicare Web

A proposed rule from HHS’ Office of the National Coordinator for Health Information Technology (ONC) could mandate the publication of prices negotiated between payer and provider organizations as well as detailed information about Medicare reimbursement, DRG prices, and bundled prices.

The proposed rule, published March 3, would implement certain provisions of the 21st Century Cures Act, including measures to implement interoperability and define electronic health information (EHI) and information blocking. According to the proposed rule, the definition of information blocking applies to EHI. However, what constitutes EHI is not specifically defined in the 21st Century Cures Act, HITECH, or related statutes. The proposed rule seeks to address that by defining EHI as:

  • Electronic protected health information (ePHI)
  • Any other information that:
    • Is transmitted by or maintained in electronic media as defined in 45 CFR 160.103
    • Identifies the individual or could reasonably be used to identify the individual
    • Relates to the past, present, or future health or condition of an individual, the provision of healthcare to an individual, or the past, present, or future payment for the provision of healthcare to an individual

This definition would apply to information created or received by a provider or those operating on behalf of a provider, health plans, healthcare clearinghouses, public health authorities, employers, life insurers, or schools. The proposed rule emphasizes the expansive nature of this definition of EHI, stating that it could include information on an individual's health insurance eligibility and benefits, billing for healthcare services, and payment information for services to be provided or already provided, which may include price information.

The proposed rule asks for stakeholder feedback on prices that should be included in the definition of EHI. Specifically, it asks whether prices included in EHI should:

  • Include a reference price as a comparison tool, such as the Medicare rate
  • Include various pricing information such as chargemaster price, negotiated prices, pricing based on CPT® codes or DRGs, bundled prices, and price to payer
  • Reflect all out-of-pocket costs such as deductibles, copayments, and coinsurance
  • Reflect the amount to be charged to and paid for the patient’s health plan and the amount to be charged to and collected from the patient, including for drugs and medical devices

The proposed rule also asks for feedback on:

  • Development of a comparison tool
  • How far in advance of services price information should be available
  • How to provide price information for unscheduled care including emergency care
  • Patient notification of billing policies
  • The use of a single bill that includes all providers involved in a service

Comments on the proposed rule are due May 3. Comments can be submitted electronically at; regular, express, or overnight mail; or hand delivered to the Office of the National Coordinator of Health IT. Comments should be identified by RIN 0955-AA01.