The Trump era Transparency in Coverage (TiC) rule released in 2020 focused on insurance companies and require that insurers make machine readable files (MRFs) of negotiated in-network rates and out-of-network allowables publicly available on their websites by July 1st, 2022. Going one step further, by January 1st, 2023, plans must make cost-sharing information available for 500 defined items and services. Estimates must be specific to a covered members’ insurance plan and in-network or out-of-network benefits. Beginning in 2024, the 500 items and services will be expanded to include all items and services except prescription medications. The requirement to publicize medication costs has been delayed indefinitely.
While many insurance plans are posting MRFs on their site, they seem to be trying to obtain a grade of D-: doing just enough to achieve compliance, but making the MRFs very difficult to work with.
Example of Machine Readable File (MRF)
This is what one would call, “hiding in plain sight.” The data files are there for the taking. However, extracting data from these gigabyte and terabyte-sized files is a herculean task. The effort to unlock this large trove of pricing data, and place it in a usable format, will lead to several benefits: Greater transparency and increased competition, leading to lower rates for consumers and the ability to know costs ahead of time, allowing them to financially plan for their healthcare needs.
But before consumers benefit from the lower costs associated with greater price transparency, providers, health systems and corporate entities must access the data. No small feat.
Example of Human Readable File (HRF) by BuildMyHealth
After much effort, coding and utilization of additional server space, our team at BuildMyHealth has “cracked the code” and created a reproducible way to extract data from these MRF’s and turn them into HRF’s (Human Readable Files)!
And if extracting the data isn’t hard enough, the data is updated each month! While the rates may not change, the carriers are required to keep their network of providers regularly updated. Which means that any data extracted in a given month, may not be accurate in the subsequent month, thus requiring us to extract and update the data on a monthly schedule. Data is extracted from the biggest payor and any additional smaller payor as requested by a client.
In the example above, you can see the comparison of negotiated rates for several procedures between Aetna and three facilities all within the city of Baton Rouge, Louisiana. For the parent companies of each facility – USPI, SCA Health and Surgery Partners – this information is helpful in determining how their negotiated rates compare amongst competitors.
Other actionable reports that can be gleaned from the insurance companies’ MRFs include:
- Rate comparisons based on CPT code and facility
- Rate comparisons based on CPT code and physician
- Comparison of intra-city rates
- Comparison of intra and interstate rates
- Comparison of in-network and out-of-network allowables
- Any customized report based on CPT, NPI, location and insurance carrier
Armed with these reports, benefits for providers include:
- Greater leverage in negotiating your next payor contract as a provider or small group practice
- More accurately assess valuation of a potential acquisition target
- Check intra-city, intra or interstate rate variation
- Determine which procedures are more suitable as an out-of-network provider
- Urologists: how does your prostatectomy reimbursement compare with the competitor down the street?
- Plastic surgeons: compare your breast reconstruction rates with the surgeon next door
- ASCs: are you getting the best rate for your facility fees?
And benefits to the consumer include:
- Ability to get pre-procedure total cost of care estimates with professional, institutional, ancillary and technical components included
- As providers and insurers negotiate, the most expensive rates will become non-existent, lowering costs for Americans!
