When the Transparent is Not Apparent: Mixed Reviews for Hospital Transparency Compliance

What you reveal to others says something about yourself. Some people are an open book while others tend to keep their cards close to the vest. Still others may go to the extreme by revealing too much information (TMI)! But on the whole, most of us appreciate transparency from each other, our government and private businesses. Transparency translates to a willingness to not hide the inconvenient facts—irrespective of the consequences. It means showing who or what you are, warts and all. When faced with the full picture, people are naturally able to make better assessments. This is the rationale behind the Hospital Price Transparency (HPT) rule implemented by the federal government.

Background

The HPT rule became effective on January 1, 2021, with the aim of giving consumers greater information about hospital costs, enabling them to make better healthcare decisions.The hope is that a more informed public will lead to better competition, with the ultimate goal of reduced prices.The rule requires hospitals to publicly post prices in two forms: (a) a machine-readable file (MRF) of standard charges for all items, services and drugs, and (b) prices for the 300 most common shoppable services, either as a consumer-friendly display or a price estimator tool.

An update to the rule in July of 2024 made the pricing files more uniform but also weakened consumers’ access to real prices. That is, the update allowed hospitals to post percentages and algorithms instead of dollar-and-cents prices. According to some, this change limited the intended efficacy of the HPT rule.

The government instituted several modifications to the HPT rule with its 2026 Outpatient Prospective Payment System (OPPS) final rule. The OPPS rule mandated, in part, that beginning January 1, 2026, “hospitals will be required to calculate and encode the median, 10th and 90th percentile allowed amounts as well as the count of allowed amounts in their machine-readable file (MRF) when payer-specific negotiated charges are based on percentages or algorithms.” The rule also tightens the use of algorithms to ensure that the public can calculate payer-specific negotiated rates. Hospital files must now provide “all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.”

So, we’ve got a lot of rules when it comes to what hospitals must provide in the way of price transparency, but a rule is only as effective as its enforcement. Toward that end, the Centers for Medicare & Medicaid Services (CMS) announced on April 1, 2026 that they would be enforcing the 2026 OPPS rule transparency provisions.

Report Card

Given the government’s determination to enforce the HPT rule, it may help to see just where hospitals currently stand as far as their compliance with the transparency requirements. As it turns out, an organization known as Patient Rights Advocate (PRA) has recently released its latest report on hospital compliance with the HPT rule. The organization reviewed the websites of a total of 2,000 hospitals, placing an emphasis on hospitals owned by the nation’s largest health systems.

A hospital was identified as noncompliant with the HPT rule if any of the following were found:

• The MRF did not conform to the required form and manner requirements put forth by CMS per the CMS Validator;
• The MRF had incomplete header information including the correct type 2 NPI;
• The attestation affirmation was “FALSE”;
• The MRF had obfuscated codes or descriptions;
• The MRF had inadequate payer and plan information;
• The MRF did not accurately post the negotiated charge percentages;
• The MRF contained greater than 10% of algorithms which did not meet the “all necessary information available to the hospital for the public to be able to derive the dollar amount” requirement; or
• The MRF’s filename format was incorrect.

Of the 2,000 hospitals reviewed, PRA presented the following findings:

• Only 988 hospitals (49.4%) were fully compliant, reflecting an increase of 28 percentage points from its previous report (21.1% compliance).This means that 1,012 hospitals (50.6%) were found to be noncompliant with the rule, and hospitals’ use of insufficient algorithms drove noncompliance.
• Only 360 (18.0%) of the 2,000 hospitals reviewed posted dollar-and-cents prices for at least half of the items and services in their files. Consumers’ access to actual, usable prices is still limited, often because of the widespread use of percentages and algorithms instead of dollar-and-cents prices.
• Hospital files passing the CMS Validator Tool increased from 73.4% to 92.8%; conforming filename formats increased from 80.4% to 90.0%; MRF name and address accuracy improved from 64.4% to 86.3%; TXT file content completeness and accuracy improved from 84.8% to 99.7%; correctly formatted negotiated charge percentages increased from 68.6% to 92.7%; and price links improved from 96.4% to 99.8%.

So, despite the fact that half of all hospitals are still not fully compliant, there are several data points in the PRA report that indicate hospitals are trending in the right direction. This is a good thing, because the government has begun enforcement actions this year; and you don’t want to get on the bad side of a federal bureaucrat.