When Opinion Dictates Compliance: A Closer Look at PRA’s Latest Transparency Report

Patient Rights Advocate’s (PRA) latest Hospital Price Transparency Compliance Report makes a dramatic claim: that more than half of U.S. hospitals are noncompliant with federal price transparency requirements. Yet a closer examination of the report reveals a very different story.

By PRA’s own findings, hospitals are overwhelmingly complying with the standards that CMS has actually established.

According to the report:

• 92.8% of hospital files passed the CMS Validator Tool.
• 99.8% posted a price transparency link.
• 99.7% provided complete and accurate TXT file content.
• 92.7% correctly formatted negotiated charge percentages.
• 90.0% followed required file naming conventions.
• 86.3% provided accurate hospital identifying information.

These are not minor technical achievements. They represent the very standards CMS created to ensure machine-readable files are accessible, usable, and compliant.

In other words, if the report focused on hospitals’ compliance with CMS’s objective requirements, it would paint a picture of industry-wide compliance rates that routinely exceed 90%.

Instead, PRA reaches a dramatically different conclusion by introducing its own interpretation of a single concept: whether hospitals provide “all necessary information” when disclosing contractual payment algorithms.

The most important fact in the entire report may be one that receives relatively little attention: PRA openly acknowledges that CMS has not clearly defined what constitutes “all necessary information.” The report states that it was unable to identify specific CMS guidance and repeatedly calls upon CMS to issue additional clarification.

That admission should give readers pause.

If CMS has not established a clear standard, then PRA is not measuring compliance against CMS requirements. It is measuring compliance against PRA’s interpretation of what those requirements should mean.

Those are two very different things.

The report’s headline conclusion depends almost entirely on this distinction. PRA found that hospitals were highly compliant with nearly every objective requirement established by CMS. Yet it reduced overall compliance rates substantially based on its own assessment of algorithm descriptions.

One is left with the impression that PRA’s real objection is not whether hospitals are disclosing reimbursement methodologies compliantly. Rather, the organization simply does not like algorithms.

The report repeatedly suggests algorithms should be restricted, standardized, simplified, or replaced with fixed negotiated dollar amounts. Yet algorithms are not a loophole hospitals invented to avoid transparency. They are a direct reflection of how hospital-payer contracts are written. Anyone with meaningful experience reviewing hospital reimbursement agreements understands this immediately.

Which raises an uncomfortable question: How can an organization effectively evaluate hospital compliance and make policy recommendations regarding reimbursement methodologies without understanding the structure and complexity of hospital contracts?

Healthcare reimbursement contracts can be complex because healthcare itself is complex. Patients receiving the same broad service often consume different levels of care, resources, medications, implants, or lengths of stay. Reimbursement methodologies account for these differences so that payment more accurately reflects the care that is actually delivered.

Far from being a weakness, hospitals and payers structuring contracts to account for this real-world complexity can benefit patients. A lower-resource case should not necessarily be reimbursed the same as a higher-resource case. The challenge is that these variables often cannot be known before treatment occurs.

CMS recognized this reality when developing the transparency requirements. Hospitals are required to disclose negotiated rates as fixed dollar amounts whenever those amounts can be accurately represented. However, reimbursement arrangements rarely exist as standalone dollar figures. More often, negotiated rates are accompanied by severity adjustments, outlier provisions, lesser-of terms, service-specific payment rules, or other contractual elements that collectively determine reimbursement.

Perhaps surprisingly, PRA continues to be unaware of these widespread and fundamental elements of hospital-payer contracts. These structures are precisely why CMS permits algorithms when a standalone dollar amount cannot fully represent the payment methodology.

Just as importantly, CMS did not stop there.

Hospitals reporting algorithms or percentages must also provide associated 10th percentile, median, and 90th percentile allowed amounts derived from actual adjudicated claims. These allowed amounts effectively translate contractual complexity into real-world dollar-and-cents reimbursement outcomes.

Hospitals that faithfully encode contractual methodologies and pair them with allowed amount reporting are doing exactly what transparency advocates should encourage. They are providing transparency into both how reimbursement is determined and what reimbursement looks like in practice. That effort should be acknowledged and appreciated, not characterized as noncompliance simply because the underlying reimbursement arrangements reflect the complexity of modern healthcare.

Ultimately, the report’s headline conclusion rests on an unsupported premise: that PRA’s interpretation of “all necessary information” should be treated as though it came from CMS. It did not.

Hospitals should absolutely be held accountable for complying with CMS requirements. But compliance assessments should be based on objective standards established by regulators, not subjective standards created by PRA. And if PRA intends to substitute its own interpretation for CMS guidance, it should be fully transparent about how those determinations are made. The report references an “independent review and validation,” yet provides limited visibility into the methodology, standards, and decision-making framework used to classify hospitals as compliant or noncompliant. Transparency is not a one-way obligation. It should apply equally to the hospitals being evaluated and the organizations performing the evaluations.

In conclusion, PRA’s own report tells a very different story than its headline suggests. While the report prominently cites a 49% compliance rate, its underlying findings show hospitals achieving compliance rates exceeding 90% across the objective standards established by CMS, including validator tool performance, file accessibility, data formatting, and other technical requirements. The gap between those results and PRA’s headline figure is driven largely by PRA’s subjective interpretation of the undefined “all necessary information” requirement. That approach does not measure compliance against the standards CMS has actually established. It measures compliance against PRA’s interpretation, substituting opinion for regulation and creating a misleading picture of hospital compliance.

CMS established compliance standards. Hospitals comply with those standards. Patient Rights Advocate should not be allowed to rewrite the rules after the fact.

For more information about how we believe algorithm descriptions could be standardized into an enhanced, machine-readable format, please see our comments submitted to CMS found here.  (https://www.cleverleyassociates.com/blog/a-response-to-the-cy27-opps-proposed-rule-request-for-information-regarding-strengthening-the-standardization-and-comparability-of-hospital-price-transparency-hpt-data/)  – or – go to the direct download (https://www.cleverleyassociates.com/wp-content/uploads/2026/08/CY27-OPPS-Proposed-Rule-Price-Transparency-RFI-A-response_Update-1.pdf)