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8/1/2025
This article first appeared as a column in the 2025 August issue of South Florida Hospital News
By Mary Mayhew, FHA President and CEO
As one of the most heavily regulated industries by federal, state, and even local governments, in addition to private accreditation entities, hospitals are no strangers to complying with regulations, ordinances, and other requirements. By one count, for example, 750 federal health-related regulations were finalized between 2005 and 2025 at an estimated cost of compliance of $313 billion dollars and 368 million paperwork hours.
When the federal government first mandated online publication of negotiated payment rates between hospitals and insurers in 2021, in addition to previous state and federal requirements to post pricing data, hospitals did what they always do and swung into gear to comply. They deployed teams comprised of information technology, finance, and data professionals to build and publish online machine-readable files in the prescribed format that provides the payment amount for every single service provided negotiated with every single health plan and insurer with which they contract.
Today, despite the immense amounts of data required and complexity of formatting and updating, fewer than 30 hospitals nationwide were deemed non-compliant with federal hospital price transparency regulations, according to the federal government.
Lost in the conversation about compliance, however, is the utility of the data for a health care consumer.
The contracted, negotiated rates provided in the mandated machine-readable files (MRFs) are not the same as a patient’s eventual out-of-pocket costs. The rates are the amount a hospital has agreed to be paid by an insurance company for an authorized medical service or procedure.
Health insurance companies have a dominant role in determining how much a patient eventually pays for that service. Health insurers, not hospitals, establish benefit coverage limits, in-network providers, and cost-sharing requirements, all of which dictate a patient’s ultimate medical bill.
In most instances, the patient will owe a portion (or none) of a negotiated payment amount based on their health plan’s cost-sharing rules. Depending on their health insurer, their benefit plan, and where they are in meeting any annual deductible or cost-sharing maximum, that specific amount can vary.
In addition, hospital MRF data offers a level of detail on prices that most consumers would not find immediately helpful when seeking to understand the cost of care. A list of shoppable services is a better, more accessible resource for consumers.
In addition, not all of a patient’s required services may be known at the time of treatment scheduling. It is entirely possible that a patient will need a different and/or additional medical intervention because of their response to medication, previously undiagnosed co-morbidity, or other complicating medical factors.
All of these reasons are why hospitals go above and beyond to comply not just with the technical requirements of the transparency regulations, but the spirit and intent: to empower patients to make informed decisions about where to get medical care and to understand their financial obligations.
On the digital side, many hospitals have built and deployed highly sophisticated online calculators that give patients the 24/7 ability to find out in advance the likely cost of any scheduled procedure or service provided at that hospital based on their individual insurance coverage.
On a more personal side, hospitals also employ financial counselors who work with patients before and after procedures or services to explain what is being provided, what is covered by their insurance, and what their out-of-pocket expenses will be. These counselors also exhaust exploring every possible third-party coverage and payment source, from Medicaid and the health insurance marketplace to co-pay assistance from pharmaceutical manufacturers, to help patients meet their financial obligations.
Hospitals understand that patients deserve personalized information, and, as their trusted local health care provider, they have taken on the responsibility of deploying online tools and employing financial advocates all with the goal of making the process more transparent and empowering patients to make more informed decisions about their health care spending.