The Centers for Medicare & Medicaid Services (“CMS”) has released the Calendar Year 2026 Hospital Outpatient Prospective Payment System Final Rule, which includes another round of substantial updates to the Hospital Price Transparency (“HPT”) regulations. The new policies aim to further standardize the data disclosed by hospitals, enhance the utility of the machine-readable files (“MRFs”) for consumers and researchers and streamline enforcement processes.
Key Points and Hospital Action Items
- The changes will require every hospital subject to the HPT regulation to review and update their existing MRFs again.
- The MRFs must meet several new requirements, some of which will require diving into claims payment data.
- Hospitals should begin updating files now in preparation for the January 1, 2026, and April 1, 2026, effective dates that apply to most of the new requirements.
- CMS is also updating its monitoring and enforcement process as part of an ongoing increase in government oversight of HPT compliance.
Here is a summary of the key updates finalized by CMS.
Refinement of Allowed Amount Data Elements: CMS is finalizing its proposal to replace the “estimated allowed amount” data element with more granular metrics. When a payer-specific negotiated charge is based on a percentage or algorithm, hospitals will now be required to disclose the following:
- Median Allowed Amount: The median of the total allowed amounts the hospital has historically received. This replaces the requirement to disclose the “estimated allowed amount.”
- Tenth (10th) Percentile Allowed Amount: The value below which 10 percent of the observed allowed amounts fall.
- Ninetieth (90th) Percentile Allowed Amount: The value below which 90 percent of the observed allowed amounts fall.
- Count of Allowed Amounts: The total number of allowed amounts used to calculate these statistics.
Hospitals must calculate these amounts using electronic data interchange 835 electronic remittance advice transaction data or an equivalent source of remittance data. The lookback period for this data has been finalized as a period of no less than 12 months and no longer than 15 months prior to the date the MRF is posted. If a hospital does not have data for an item or service that goes back 12 months, it must encode “0” for the count of allowed amounts and leave the median and percentile fields blank.
It is worth noting that the “estimated allowed amount” data element, which is being replaced by the median allowed amount, was a relatively recent requirement that proved difficult for many hospitals to comply with due to varying contract structures and data limitations. The shift to median and percentile amounts aims to provide a more standardized and comparable figure for consumers and researchers.
New Attestation Requirements: To ensure data accuracy and accountability, CMS is strengthening the attestation requirements for the MRF. Hospitals must now include a statement attesting that, to the best of the hospital’s knowledge and belief, all applicable standard charge information has been included and is true, accurate and complete. This attestation must also confirm that for charges not expressed as a dollar amount, the hospital has provided all necessary information for the public to derive the dollar amount.
Crucially, hospitals must encode the name of the Chief Executive Officer, President or a senior official designated to oversee the encoding of this data within the MRF itself.
Inclusion of National Provider Identifiers (“NPIs”): To improve the comparability of HPT data with other datasets, such as the Transparency in Coverage files, CMS is finalizing the requirement for hospitals to encode their organizational Type 2 NPIs in the MRF. This requirement applies to NPIs associated with a primary taxonomy code indicating a hospital (’28’) or hospital unit (’27’).
Civil Monetary Penalties (“CMPs”) Reduction: In an effort to resolve compliance actions more efficiently, CMS is updating its enforcement regulations. Hospitals that receive a notice of imposition of a CMP will be eligible for a 35 percent reduction in the penalty amount if they waive their right to an Administrative Law Judge hearing within 30 calendar days. This reduction is unavailable to hospitals that fail to post an MRF or a consumer-friendly list of shoppable services entirely, as these are considered “core” HPT requirements. Hospitals should think carefully before waiving their right to a hearing, as this involves relinquishing the opportunity to contest the penalty.
Implementation Timeline: While the effective date for these new policies is January 1, 2026, CMS has finalized a delay in enforcement. Hospitals will have until April 1, 2026, to come into compliance with the new requirements regarding the median and percentile allowed amounts, attestation and NPI encoding.
Practical Takeaways
These updates represent a continued push by CMS towards greater standardization and transparency in hospital pricing. Hospitals should begin evaluating their current data capabilities and preparing for these new reporting obligations well ahead of the enforcement deadline.
If you have any questions regarding these new requirements or need assistance with compliance strategies, please contact:
- Benjamin Fee at (720) 282-2030 or bfee@hallrender.com;
- Lori Wink at (414) 721-0456 or lwink@hallrender.com; or
- Your primary Hall Render contact.
Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot—outside of an attorney-client relationship—answer specific questions that would be legal advice.
