Payers have Posted Prices… Now What?
In case you missed the news, July 1 was a major milestone for price transparency in healthcare. Health plans (and our HealthSparq team) have been preparing for months for the phase one enforcement date of the Transparency in Coverage Final Rule (CMS-9915-F). A few headlines gave an indication that something big is happening.
This phase of the mandate required payers to post their in-network rates (the agreed upon amount that an insurer will give to a provider after seeing a member for a particular service) as well as the plan’s historical out-of-network payments using claims data (meaning, the amount paid when someone sees a provider with whom the insurer has no contract). While the format of the data that payers are required to provide is unreadable by humans in general (aptly named machine-readable files or MRFs), this step is groundbreaking. These MRFs lay the foundation for sharing important cost information with people over the next two deadlines.
So what happens now?
The Machines are Coming
MRFs provide public access to negotiated rates between payers and providers. However, these files are in JSON or XML formats to be loaded into computers for analysis by healthcare researchers. The files are not usable for the general public or health plan members to determine what they will pay out-of-pocket for care–that starts January 1, 2023. The MRF data provides great value to health insurers and self-insured groups looking to benchmark their negotiated rates in their markets. In fact, a survey by Deloitte found that 76% of health plans said that they will pursue technology investments for analytics on competitive and market prices.
Plans Still Have Work to Do
Not every health plan has yet to post their MRFs, which isn’t surprising since collecting this data is no easy feat. We’re also seeing a bit of non-compliance with the mandates such as posting in unacceptable file formats, missing files for certain lines of business, and not creating a table of contents when reporting multiple plans in one file. Some plans have set up automatic downloading of just index or table of content files, and one even has even gone so far as to post text for a URL with instructions to copy and paste it to initiate a downloaded index file.
Jan. 1, 2023 Is Around the Corner
The benefits of the new rule will be clearer to consumers after January 1, 2023, and even more so after the January 1, 2024 deadline. Here’s what to expect coming up:
The v1 of a self-service tool will be live on health plan websites (or updates to their existing tool will be made) sharing personalized, out-of-pocket cost estimates for 500 items and services based on negotiated rates. This is when the rubber really hits the road for price transparency, putting the information consumers need in a tool that they can navigate on their own (without another company scraping the data for them). However, just using MRFs to generate costs at the billing code level can deliver a fragmented and confusing experience for health plan members. Plans will need to go beyond the mandate minimums to deliver a helpful experience for members.
The final deadline for price transparency where health plans will have to share out-of-pocket cost information for all covered health care items and services through an internet-based self-service tool, by phone, and in paper form upon request with all members.
HealthSparq has been working to help people understand healthcare costs for over a decade and we support the boost to transparency that government mandates are providing. We also know that people need more than just cost to navigate healthcare. People want more context and they want more help to search, compare, and select care.
MRFs build a foundation for transparency but that foundation alone is not enough. Learn how HealthSparq can help your team.