Health Care Pricing Transparency Rules and Their Impact on Compliance

Understanding the costs of health care has been a challenge for American consumers for many years. Patients are often unaware of how much they will be charged for services and treatments until they receive a bill, sometimes weeks or months later. Health care price transparency is critical, as the high cost of health care is a significant burden on families and a major factor in their health care decisions, with unexpected medical bills being a top financial concern for many families.¹ Unpredictable health care costs and hospital billing prices are also a problem for employers who provide health insurance plans for their employees and need to budget for the financial impact of that coverage.

Aiming to address these challenges, the White House issued an Executive Order on February 25, 2025, entitled “Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information.” This Executive Order builds on the 2019 Executive Order, which was titled “Improving Price and Quality Transparency in American Healthcare to Put Patients First” and required hospitals and health plans to maintain and share service prices and negotiated payment rates with consumers and other health care entities.

The 2025 health care pricing transparency Executive Order instructs federal agencies to require health care providers to disclose actual (not estimated) prices of items and services. These changes aim to reflect the reality that cost is a major factor for consumers when purchasing health products and give consumers tools to make informed decisions. It also orders that enforcement policies be updated and increased to ensure compliance with these medical price transparency requirements.

Previous Actions on Health Care Price Transparency

The U.S. Department of Health & Human Services (HHS) issued the Hospital Price Transparency Final Rule in 2019, and the rule took effect in January 2021. Early analyses of the rule’s impact showed that hospital compliance with the rule was low, so the agency increased penalties for non-compliant hospitals and required quicker corrective actions. However, compliance with the rule continues to lag, and hospital price transparency has not noticeably improved for most consumers.

The 2020 Transparency in Coverage Final Rule required most health plans and issuers to post machine-readable files online, disclosing information about their coverage and costs to the public, for plan years beginning on or after January 1, 2022. Required information included rates for in-network and out-of-network services and prescription drugs, cost-sharing, and estimates of out-of-pocket costs. It also required plans to provide internet-based price comparison tools for all covered items and services. However, government enforcement of these requirements has been deferred and delayed, and despite the CMS website stating that “most group health plans and issuers of group or individual health insurance are posting pricing information for covered items and services,”² the benefit to consumers remains questionable.

The No Surprises Act, which took effect January 1, 2022, protects patients from unexpected billing for out-of-network services received at in-network facilities, also known as "surprise balance billing." This happens when an out-of-network provider sends a patient a bill for services that they provided when the patient sought care at an in-network provider, and the amount they charge is greater than what the patient's health insurance covers. There are situations where a patient is unaware that an out-of-network provider has treated them, such as when a patient must go to the nearest hospital for an emergency medical situation, or when a patient has surgery at an in-network hospital but a member of the surgical team (e.g., the anesthesiologist) is out-of-network. While not an official price transparency rule, the No Surprises Act is related to transparency efforts in that it aims to restrict the proliferation of "surprise" medical bills that have also made health care costs unpredictable and unaffordable for many American families.

Preparing for New Rules and Enforcement

Health care compliance professionals should be preparing to comply with upcoming rules and increased enforcement activity regarding transparency of hospital prices and health plan rates.³ This could mean ramping up internal auditing and evaluation of pricing data, confirming compliance with current transparency requirements, and putting systems in place that will allow real-time updates and reporting of the latest pricing and rate information. Health care organizations that already have strong price transparency processes in place will be better equipped for the new rules and will experience the least disruption due to current and future regulations in this area.

Compliance professionals should already be overseeing their organizations’ adherence to the No Surprises Act’s prohibitions by taking steps to ensure that out-of-network providers do not send surprise balance bills for emergency treatment or care provided at an in-network hospital. By also complying with the health care price transparency rules, organizations will enable patients to confirm that they were only charged their regular in-network hospital billing prices.

Many technology companies are currently developing and marketing health care pricing transparency tools and services to help organizations prepare for increased scrutiny and enforcement. While these tools can play an important role in helping organizations produce accurate and timely cost estimates and prepare for potential audits, compliance leaders will need to be intimately familiar with the medical price transparency requirements and develop efficient processes to stay on top of current requirements. A compliance officer who thoroughly understands the existing and new health care price transparency requirements will be better prepared to help the organization achieve and maintain full and timely compliance.

Down the road, compliance with these requirements may lead to increased revenue and decreased collection efforts, as patients indicate that understanding their costs before health care services are received leads to a better payment experience.⁴ Importantly, organizations whose leaders prioritize compliance requirements are likely to improve overall satisfaction by recognizing the impact of health care price transparency on patient decisions.

Develop Expertise in Compliance Regulations for Health Care Price Transparency

Gain the foundational knowledge you need to enhance compliance with medical price transparency requirements. The University of Pittsburgh’s Online Master of Studies in Law will equip you with a strong understanding of applicable U.S. laws and legal procedures. Along with core classes on key aspects of the law, you can specialize in health care compliance.

If you are looking to make a bigger impact in health care but aren’t ready to pursue a full degree, consider our Health Care Compliance Certificate program. Taught by legal experts, this stand-alone certificate will help you develop a deep understanding of compliance best practices and regulations.

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