GAO: CMS failed to ensure price transparency data accuracy

CMS fails to monitor pricing data accuracy, completeness

But GAO contended that CMS is not actually doing its part in monitoring price data completeness and accuracy.

Indeed, the agency has issued a number of hospital price transparency enforcement actions. Since the rule's implementation, CMS has issued 1,287 enforcement actions, 851 of which were initiated in 2023. The agency has issued over $4 million in civil monetary penalties to 14 hospitals that did not take timely corrective action, the GAO report added.

But those enforcement actions didn't happen because CMS itself monitored and flagged issues with price transparency data, GAO said.

"While CMS also has the ability to self-initiate audits of hospital websites and reviews of hospital compliance, CMS officials told us that they believed prioritizing complaints was the most effective approach to target reviews on hospitals at higher risk for noncompliance," GAO explained.

CMS faces an uphill battle monitoring pricing data compliance

CMS officials told GAO that they begin compliance reviews by examining public complaints submitted on the agency's website. Agency officials score those complaints, giving priority to complaints about a lack of machine-readable files or hospitals with multiple complaints filed against them.

From there, CMS officials use checklists to ensure key price transparency requirements are met. Those requirements include having all of the mandatory prices for applicable items and services on the list, listing item and service billing codes and descriptions and meeting accessibility criteria.

If CMS verifies deficiencies with the hospital's price transparency files, the agency issues a warning notice outlining the issues and instructions for rectifying them, to be completed within 90 days.

Noncompliance with the warning notice results in a request for a corrective action plan. If a hospital does not fulfill any of the required corrective actions, CMS issues a civil monetary penalty of $5,500 per day, depending upon the hospital's size. CMS closes the case once the hospital has taken all corrective action steps.

GAO did note that CMS expressed plans to take other approaches to monitor hospitals for compliance in addition to public complaints. For example, implementing a standardized file format should make it easier for the agency to conduct its own audits. CMS also suggested that certain 2024 updates to the price transparency rule's requirements should make it easier for hospitals to comply.

Still, GAO indicated that CMS is failing to ensure pricing data is complete and accurate.

"CMS's updates to hospital price transparency requirements are positive efforts toward ensuring the usability of such data," the GAO report stated. "However, CMS does not have assurance that the data hospitals report are sufficiently complete and accurate."

CMS officials said that they do not ensure data accuracy or completeness because they handle a significant amount of data, meaning a significant workload the agency's workforce could not feasibly take on.

"According to CMS officials, the agency's approach to enforcement of hospital machine-readable files prioritizes ensuring that hospitals comply with basic reporting requirements, such as ensuring the files include data for all five of the required types of prices and corresponding item and service billing codes and descriptions," GAO explained. "CMS officials stated that this enforcement approach represents the most effective use of agency resources."

CMS did note plans to make monitoring of pricing data simpler for agency officials and expressed hope that a more workable posting system for hospitals would prevent noncompliance. However, GAO still recommended the CMS Administrator create a detailed plan to check the accuracy and completeness of pricing data, which CMS agreed with.

Sara Heath has covered news related to patient engagement and health equity since 2015.