Who's On for Compliance? Navigating Healthcare Price Transparency and the Current Regulations | PurpleLab®

The healthcare industry is undergoing a seismic shift as price transparency regulations gain momentum, driven by executive orders and federal rulemaking. These regulations aim to empower patients with actionable pricing information and foster accountability among healthcare providers and payers. However, enforcement challenges and data complexities have revealed gaps that need innovative solutions. In this article, we explore the evolving landscape of price transparency, its regulatory intricacies, and how PurpleLab® is uniquely positioned to address these challenges. 

 

What is the Foundation of Price Transparency Regulations? 

Price transparency initiatives stem from a 2019 executive order focused on enabling patients to make informed economic decisions about their care. The framework includes three key rules: 

• Surprise Billing Protections: These regulations under the No Surprises Act shield patients from unexpected out-of-network charges for emergency care and transportation. They also establish dispute resolution pathways and appeal mechanisms for health plan decisions. 

• Hospital Price Transparency Rule: Hospitals must disclose standard charges for at least 300 items and services, including gross charges, discounted rates, and payer-specific negotiated prices. This information must be available in machine-readable files and consumer-friendly estimator tools. 

• Transparency in Coverage Rule: Health plans must provide cost-sharing information for 500 covered items and services, along with in-network negotiated rates, historical out-of-network allowed amounts, and drug pricing details. Similar to hospitals, plans must publish this data in machine-readable files and accessible estimator tools. 

 

What’s the Latest with Evolving Regulatory Requirements? 

Since the finalization of these rules, updates have been implemented to refine technical requirements and expand reporting obligations: 

• Hospitals now use CMS-provided templates to ensure consistency in reporting payer-specific negotiated charges. 

• Health plans face increased scrutiny under the Transparency in Coverage rule, with agencies like HHS, the Department of Labor, and state governments involved in enforcement. Recent FAQs have clarified provisions while rescinding enforcement delays for prescription drug pricing requirements. 

Despite these advancements, enforcement remains a significant challenge due to resource constraints and the sheer volume of data requiring review. For example, CMS relies on complaint-based compliance reviews rather than comprehensive audits of hospitals or health plans. 

 

What Are the Main Challenges in Enforcement? 

Enforcement of price transparency regulations varies widely across states and federal agencies: 

• Surprise Billing: CMS operates a No Surprises help desk to manage complaints but faces delays in closing cases due to jurisdictional complexities. 

• Hospital Price Transparency: Compliance has improved following increased penalties (up to $5,500 per day), yet enforcement remains limited by CMS’s capacity to conduct reviews—currently capped at 40 per month. 

• Transparency in Coverage: While health plans are posting machine-readable files as required, the size and complexity of these files pose challenges for meaningful review and enforcement coordination across multiple agencies. 

President Trump’s recent executive order aims to advance enforcement by empowering patients with clearer pricing information. However, achieving this goal requires more resources for policy clarification, additional regulations, and partnerships with private industry to leverage analytics capabilities. 

 

Looking Ahead: Where Are Opportunities for Collaboration? 

As price transparency regulations continue to evolve, collaboration between government agencies and private industry is critical for success. PurpleLab’s expertise in healthcare analytics positions it as a valuable partner in driving compliance and enhancing enforcement efforts through advanced data solutions. 

Price transparency represents not just a regulatory challenge but an opportunity to revolutionize healthcare decision-making for patients, providers, payers, and policymakers alike. By bridging gaps in data accuracy and usability, PurpleLab is paving the way for a more transparent healthcare system that benefits all stakeholders. 

 

How Can PurpleLab Transform Price Transparency Regulation? 

PurpleLab’s Trusted Price Intelligence offers a groundbreaking solution to address the complexities of price transparency data management. By combining payer data, hospital price transparency data, and claims information into a unified source of truth, PurpleLab delivers actionable insights that benefit stakeholders across the healthcare ecosystem.

This article originated as an interview with Modern Healthcare’s Angie Stewart on April 7, 2025 for their Healthcare Insider Podcast. Listen to the Podcast here.