3 ways the Hospital Price Transparency rule is going to affect RCM

When the Centers for Medicare and Medicaid Services (CMS) brought about the Hospital Price Transparency rule, it received a mixed review. According to CMS, the rule was to be effective from January 1, 2021, and focused on helping American patients know how much hospital services would cost.

Apart from hospitals and private practices, another category of people who received the information with mixed feelings was the revenue cycle management companies. They are the ones who will actually have to make drastic changes to their processes, learn and unlearn the new regulations, and still maintain SLAs!

We’ll briefly discuss what the rule entails before discussing how it will affect RCM.

What is the Hospital Price Transparency rule?

According to this rule, hospitals that function in the United States will have to provide clear pricing information on their websites so that patients can know how much they have to spend before getting a treatment or a service.

Such information will have to be provided in two forms.

  • A machine-readable, comprehensive file that lists all the services and items
  • A list of at least 300 shoppable services that are written in plain, customer-friendly language and format

Why has the Hospital Price Transparency rule received mixed reviews?

In simple terms, the rule may complicate the existing processes followed by hospitals and revenue cycle management companies, forcing them to make quick changes and adapt. While medical billing and coding is already a field bound by rules and regulations, this will add more such regulations to the list.

A KLAS research report claims that most revenue cycle leaders are still struggling to understand the compliance facts and are dissatisfied with the rule. PatientRightsAdvocate.org released a survey report one year after the rule was implemented. It states that less than 20% of hospitals in the country comply with the price transparency rule as of early 2022. The number should go up in the coming months.

Three ways the Price Transparency rule will affect RCM

Healthcare Revenue Cycle Management includes processes that help with claims processing, billing, and revenue collection in the healthcare industry.

Usually, third-party revenue cycle management companies or internal medical billing and coding teams handle the backend medical billing and reimbursement processes and contribute directly to tracking revenues. So, of course, the price transparency rule is going to affect RCM considerably. Here are three ways we feel it would shake the RCM industry.

  • Additional responsibilities

When patients can access cost-related information beforehand, they come pre-equipped with billing and cost-related information. The challenge comes when they receive a bill that differs (mostly higher) from what they assumed. It becomes important for revenue cycle management companies to refine their billing and coding process so it is self-explanatory and services are accurately billed. Apart from having to deal with queries from the payer (insurance company), hospitals may now have to answer a lot of queries from co-payers. Unless the RCM process is strong enough to handle these queries, there is going to be a lot of chaos.

  • Dealing with compliances

Compliances have always been a large part of RCM processes, and with the price transparency rule in place, this is only going to get more complicated. While medical billers and coders who are part of third-party revenue cycle management companies go through periodical training and learning to stay updated on changing ICD codes and other terms and conditions, this rule means that such companies have to be ready to spend more on training their employees yet again.

In such cases, working with brands like Quintessence may be your best bet. We have always been a learning and training-based organization and believe in equipping our employees with the latest skills to provide exceptional RCM services to our clients consistently. While this is a new challenge thrown to us, we are already working on beating this and adhering to the new changes, without any negative effect on our clients’ solutions and services.

  • The need for additional resources

When we say there will be a need for adding resources to the RCM cycle, it includes both manpower and technological resources. Your existing billing and coding services could be running on a specific software platform. The tools may be equipped to handle certain compliances and conditions. However, the new rule could mean that your software may become insufficient to handle the changes.

Also, your existing workforce may be inadept, skill-wise or man-hours-wise, to handle the new changes. That could be an extremely big problem because increasing the number of employees, without any change in the revenues that these revenue cycle management companies generate, is going to cause a considerable dip in their revenues. Not all medical billing and coding brands can afford to do this.

Technological resources also don’t come cheap. It may take hundreds of thousands of dollars to add specific automation that the new change needs. If your billing and coding team thinks that AI could be the answer to creating tight-bound, effective RCM processes that can handle the new changes, that is an extensive investment of both money and time that you may have to make.

Quintessence, in this way, is sorted. Most of our tools are already inclined towards AI and ML, and automation is everywhere in our solutions. Our tools like Reimburssence and Codessence are created to learn with every new change and adapt to them quickly and effortlessly.


The Hospital price Transparency rule is already being followed by about 20% of healthcare practices in the country. The others are still finding their way through the compliances and requirements. Unless something drastic happens, the rule will be here to stay. Hospitals and revenue cycle management companies have to start thinking of ways to survive with the new rule and ensure their revenues, productivity, and other vital rates don’t drop.

Hiring a third-party RCM company could be advantageous at this point in time if you don’t want to take up the hassles of wading through additional compliance regulations. Talk to experts from Quintessence to know what solutions we have in place to handle the price transparency rule.

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