In 2021, Centers for Medicare & Medicaid Services (CMS) issued a rule regarding hospital price transparency to better inform patients and healthcare purchasers about the cost of care. The goal of the rule was to make it easier to shop and compare prices across hospitals, making it easier to estimate costs before receiving care. Hospitals in the U.S. are required to publish pricing data online where it is easily attainable. This pricing information must be provided in two ways:
- Machine-Readable Files (MRFs): Hospitals must publish a comprehensive MRF with all items and services. This file is intended for payers, employers, researchers, and other advanced users who analyze pricing at scale and includes certain pricing types, such as gross charges, discounted cash prices, and payer specific negotiated rates.
- Consumer Friendly Format: Hospitals should display a list of shoppable services in a consumer-friendly format of at least 300 shoppable services a consumer can schedule in advance, allowing patients to view and compare expected costs for common procedures.
While hospitals were able to comply by posting required pricing files online, incomplete and inconsistent data made the information difficult to use. This is expected to change starting in 2026. The CMS Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Final Rule clarifies hospital price transparency guidance to ensure that meaningful, accurate information is reported regarding the amount charged for health care items and services.
CMS finalized several updates that will significantly expand what must be included in MRFs. CMS is eliminating the use of “estimated allowed amounts” and requiring that hospitals replace it with the actual dollar amounts, which include three things; (1) median allowed amount, (2) the 10th and 90th percentile allowed amounts, and (3) the count of allowed amounts. To ensure consistency, hospitals must calculate those three values using electronic data interchange (EDI) 835 electronic remittance advice (ERA) or an equivalent alternative, with a look back period between 12 and 15 months.
New requirements are also stricter, with hospitals needing to attest that all data is true, accurate, and complete. They must also attest that all payer-specific negotiated charges are included. Hospitals are required to list their CEO, president, or designated senior official in the file, and they must include their Organizational Type 2 National Provider Identifier(s) (NPIs) in the MRFs to further align hospital price transparency data with other administrative and claims-based datasets.
This CMS rule update took effect January 1, 2026, with delayed enforcement until April 1, 2026. This delay will give hospitals additional time to update systems, validate data, and ensure compliance with the new requirements.
To ensure compliance and encourage faster implementation, CMS is updating their penalty process. Non-compliant hospitals that waive their right to an administrative law judge hearing may receive a 35% reduction in civil penalties, except in cases involving core failures, such as failing to publish a machine-readable file or pricing information in a consumer-friendly format. With expanded reporting requirements and stronger enforcement, hospitals and stakeholders alike will have to adapt to these changes.
These revisions shift hospital price transparency to a more practical source of insight. By requiring hospitals to report pricing based on allowed amounts along with median and percentile allowed amounts, CMS aims to improve the accuracy and comparability of pricing data. If clearer data is available based on these changes, stakeholders will have more credible pricing benchmarks that can be used to support negotiations. With calculations being uniform across hospitals, stakeholders will also be able to review the pricing variation among competitors. While there are still some limitations, these changes should improve the usefulness of hospital price files as a resource for managing healthcare costs.