Cleverley + Associates’ Interpretation of CMS Guidance on Encoding Outlier Contracting Clauses

CMS recently issued additional guidance regarding the disclosure of outlier contracting provisions within Hospital Price Transparency machine-readable files (MRFs). After reviewing this guidance, our assessment is that the current Cleverley +Associates implementation remains consistent with CMS requirements and recommendations.

Specifically, CMS states that hospitals should encode outlier contracting clauses in the required “payer-specific negotiated charge: algorithm” field when those provisions are specific to an individual item or service. CMS further indicates that hospitals may use the optional “general contract provisions” field when outlier provisions apply broadly across an entire payer contract or across multiple items and services.

Our current approach is to incorporate applicable outlier language directly within the relevant standard charge algorithm fields associated with the specific inpatient or outpatient services to which those provisions apply. This methodology aligns with CMS’s guidance for service-specific outlier provisions and ensures that the information is presented in the context of the charges and payment methodologies to which it relates.

As CMS continues to refine its Hospital Price Transparency guidance, we will monitor any future clarifications and adjust our recommendations as necessary.