Now What:  Payers' Transparency in Coverage Deadline Has Passed

Now What:  Payers' Transparency in Coverage Deadline Has Passed

What Healthcare Providers Can Expect

By Morgan Atkins
Vice President, Product and Innovation

In an effort to help consumers better understand the costs associated with healthcare, as of July 1, 2022, health plans are required to post pricing information for covered items and services, as well as publish provider-specific reimbursement rates in machine-readable file formats on the internet. 

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A part of the Transparency in Coverage: Final Rule and No Surprises Act, the new requirement also requires payers to disclose in-network provider rates, historical out-of-network allowed amounts and the associated billed charges, and negotiated rates for select prescription drugs. The Transparency in Coverage: Final Rule, which will be implemented in three stages over the next two years, is the latest step in a greater government-led effort to help consumers better understand, estimate, and even comparison shop for healthcare items and services, while simultaneously helping reign in healthcare costs nationwide. (The United States consistently spends significantly more on health care than other nations, both on a per-capita basis and relative to its wealth.) 

So, it’s mid-July and the much-anticipated deadline has come and gone, begging the question: On July 1, was it like flipping a switch, in that those participating in individual and group health insurance plans suddenly have access to the information they need to plan for out-of-pocket expenses and make value-based healthcare decisions? Do providers - from health systems and hospitals to physician practices and ancillary service providers - suddenly have access to information they can use to negotiate better reimbursement rates for themselves? Yes…and no.

According to our sampling of health plan websites over the last several days, yes, many are complying with the Final Rule mandate. However, because their published files are “machine-readable,” most - if not all - average consumers and analysts will remain in the dark, because machine-readable files can be incredibly challenging to decipher, analyze, visualize, and compare. Unlike provider files, which can be manipulated via Excel, the health plan files are much larger in size and only available via JSON and XML. 

This is why our team created the Market Reimbursement Analyzer (MRA) tool. MRA provides detailed information and digestible insights from claims reimbursement data specific to your own hospital or health system AND for competing healthcare providers, via a proprietary, well-curated, regularly updated All-Payers Claims Data (APCD) set. (You can learn more about the many ways to utilize insights from APCD in this whitepaper.) With MRA, you can leverage clean, comprehensive remit data to quickly and easily compare payment models and reimbursement rates by payer, as well as identify rate trends across service lines. Armed with this intelligence, you’ll be positioned to enter payer negotiations more confidently. You’ll also be able to identify acquisition targets with the highest potential for success and accurately determine the potential ROI of entering a new market. 

Want to chat about the Transparency in Coverage: Final Rule or learn more about our MRA software solution? Let’s connect.

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