We all dream of a world where we can quickly and easily shop for healthcare services with accurate healthcare cost estimates. On July 1, 2022, under the Transparency in Coverage (TiC) Final Rule, machine readable files were to be published and readily available for consumption and the prevailing thought was that it would be great to leverage these for online shopping tools. These transparency requirements were believed to be the silver bullet for price transparency in healthcare, but they presented unanticipated challenges along the way.
Two years have passed since the deadline for payers to publish MRFs. During this time, we’ve gained valuable insights and lessons on helping payers implement the mandate for their online shopping tool. While we may have been skeptical prior to this deadline, we remained optimistic about the promise to healthcare consumers. Before I share some lessons learned, let me recap these last few years.
To make healthcare pricing information available to the public, the tri-Departments (Labor, HHS, and the Treasury) enforced public disclosure requirements on most group health plans and issuers of group or individual health insurance. The Centers for Medicare & Medicaid Services (CMS) defined three stages to achieve compliance and provide accurate, consumer-friendly pricing information.
- Stage 1 on July 1, 2022, CMS required publicly available machine-readable files containing in-network rates for covered items and services and allowed amounts for out-of-network providers.
- Stage 2 began on January 1, 2023, making online price estimators a requirement. These member-facing shopping tools must contain a minimum of 500 common services and items.
- Stage 3 started on January 1, 2024, introducing the requirement for all items and services covered by a plan to be available in the member-facing shopping tool. In all cases, like the in-network MRF, these online price transparency tools are required to provide the member with the in-network rate that has been negotiated with a specific healthcare provider.
Since the in-network negotiated rates are readily available in the associated MRFs, they are a logical source to surface the required rates to shopping members. However, we have worked diligently for over two years to make these mandates a reality, and we have come to the hard truth that while the files and rates are online, it is not as easy as it may seem.
An immense amount of data wrangling, aggregation, mapping, and augmentation needs to be applied to make the data usable. Even after ensuring data hygiene, the healthcare shopping experience becomes overwhelming as the consumer must navigate thousands of items and services that they may not understand, as they try and find the estimate they are looking for. These mandates are helping empower patients with accurate information and out-of-pocket cost estimates to drive more informed decisions; but we still have a way to go.
Below are a few examples of where schema ambiguities and diverse interpretations of the requirements can lead to confusion when taking MRFs at face value.
The regulatory goal is to enable price transparency and surface accurate disclosure of provider negotiated rates. With this, data elements impacting contracted rates are required. Take billing_code_modifier as an example; the in-network schema indicates that this field is not required. We know that there are many modifiers in the underlying source data. Understandably, informational modifiers are not required; they do not impact rates. On the other hand, pricing modifiers are specifically designed to indicate when a pricing change is necessary based on that modifier. The field definition makes this “situational” requirement clear; however, the schema confuses this by: Required “No.”
Diving deeper into this example, radiology services vary based on multiple components that can go into a service. Often, there is the technical component for the technician and medical equipment to capture the image and a professional component for the radiologist to read the image and diagnose. Because it is important to differentiate these rates, billing_code_modifer and other data elements in the schema that are required based on specific situations (such as impact to a negotiated rate) should be labeled Required: “Situational”, which then directs the reader to the definition to clarify in what situations the data is required.
This simple update to the schema, requiring little lift, will help align the industry and ensure public and member-facing rate disclosures are more accurate and complete.
Data augmentation is essential to make the MRFs meaningful. There is a lot of superfluous data in the MRFs that greatly inflate file sizes and data that does not translate well to the consumer. By way of example, many in-network files are ballooned in size due to plans and issuers that use global contracts with multi-specialty groups. This results in every specialist participating with the contracting provider having contracted rates for all other specialists in the organization. As an artifact of this contracting arrangement, many MRFs contain rates for services that a provider will never render to a member because it is outside their scope. For example, rates for knee aspiration for an ophthalmologist.
Another example is ‘percent of charges’ contract arrangements. The regulatory requirement calls for all rates disclosed in the MRFs to be expressed as a dollar amount. On the CMS GitHub transparency website, there was some relaxing of this, allowing MRF creators to include a percent of billed charges rather than an actual dollar amount. This offers little value to consumers.
Given the complexities of leveraging in-network rates contained in the MRFs, we apply our deep experience in member-facing transparency tools, healthcare expertise, best-of-class data management, data assets, and healthcare education assets to wade through all this noise and inform the consumer.
Simply checking the compliance boxes for TiC will frustrate your members rather than help them make more informed, cost-effective choices.
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We have made it clear in the content above that leveraging in-network MRFs “as-is” will not lead to an ideal member transparency experience. In fact, in their current state, they will cause more confusion if we do not solve their deficiencies.
Truven by Merative is leveraging our deep knowledge and experience in healthcare data and the price transparency space to supplement the MRFs to solve many of these issues – advancing from a compliance exercise to provide meaningful value-add experience for members shopping for their healthcare needs.
We continue to be advocates in the member transparency space. From demonstrating our Treatment Cost Calculator for CMS as they worked on the TiC proposed rule to responding to the Department’s request for information (RFI) on the Advanced Explanation of Benefits (AEOB) – where, like many in the industry, we advocated for a limited set of shoppable services to remain in the tool, while advising “all items and services” both in the shopping tool and the AEOB was an administrative burden, and best rendered to members via the AEOB process, to submitting suggested updates and clarifications to the MRF schemas (some noted above).
Read our AEOB response
We understand that it may take years to fine-tune and iterate on the initial requirements to reach the desired endgame. However, MRFs have been online for over two years, and we have yet to see any clarifying updates to the MRFs requirement. Our focus has been to reach the destination sooner, rather than later. If we leverage machine-readable files in their current state, we risk leaving consumer confidence in the dust, which is why Truven is solving these challenges now while the requirements and guidance evolve and improve at a slower pace.
Let us help you make the most of your public MRFs and member price transparency journey. We have successfully enabled our Truven Treatment Cost Calculator, now informed by in-network negotiated rates as required by the Departments, and we offer a wide range of tools and services—from MRF creation to a web-based member-facing tool and a transparency API to support a wide range of price estimators and consumer engagement initiatives.
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