Kaitlin Howard

By Kaitlin Howard

Kaitlin Howard is a researcher and writer producing insightful content across the healthcare revenue cycle. She has written and produced content for Zelis, Waystar, and Recondo Technology, as well as agencies. With a B.A. in English and Writing from University of Denver, Kaitlin stays current on market updates on claims management and healthcare payments, publishing a regular educational blog series on industry trends and Zelis offerings.

In October 2020, HHS and the Departments of Labor and Treasury finalized the Transparency in Coverage (TiC) final rule. But it wasn’t until recently, specifically July 1, 2022, that the rule went into effect.

If you’ve been following along, you already know that the final rule requires health insurers to disclose pricing for covered services and items. Insurers must include provider-negotiated rates, as well as allowed billable amounts (aka the maximum accepted price for a given service) for all out-of-network providers.

The idea behind the policy is that information will be used to help consumers better understand the care they receive and enable them to shop around for the option that will best meet their individual needs, but given the complexity, it continues to be complicated and costly for payers to comply.

Enter Machine-Readable Files (MRF)

The TiC rules require providers to ultimately publish standard charges in a (emphasis here) consumer-friendly format. But despite best efforts, even full health plan compliance won’t automatically give consumers the information they need.

An MRF, or Machine Readable File, is a digital representation of data or information in a file that can be imported or read by a computer system for further processing. To satisfy the regulation, these files must be produced in a specific CMS-defined format, called JSON, and are not meant for direct consumption by a consumer. Rather, they are meant to provide a common data framework that, in turn, enables consumer-facing tools to display accurate cost information.

Let us explain.

If you contract your own network, you’re obligated to create an MRF file. If you rent, you’ll be given this file. On its own, however, said file isn’t actually enough to derive cost information.

Rather, your MRF files must then be adjusted to include all client Employer Identification Numbers in a new MRF file. The file should also represent your highest numbers, to the extent that you have insured plan offerings, as well as plan names.

Aka: your MRF data needs to be augmented.

Your data must also be combined with a presence of historical claims data to match the MRF cost data to services that are actually performed by providers.

With all of the underlying MRF data required for your membership in hand, the last step to compliance is displaying the transparent cost data in a user experience that is useful and helpful to the member. That’s the key.

A twofold approach.

Meeting the TiC rule helps payers come into compliance with portions of the No Surprises Act (NSA), as well. The most significant connection boils down to the internet-based tool.

In order to reach full compliance, service rates must be displayed in a machine-readable format, updated monthly, on a public-facing site.

Moreover, a member-facing digital tool must be made available to display the costs for the 500 shoppable services (and ultimately all services by 1/1/2024) described in the regulation. This allows members to see the cost for services with any applicable cost share, whether that be deductible co-pays or out-of-pocket maximums. Disclosures of any service prerequisites, as well as billing potential must also be readily available.

The NSA has quite a few member protections. One of which ensures that those who unintentionally see an out-of-network provider don’t get slapped with a much larger bill than expected after the fact. The digital tool required for TiC compliance helps with just that.

Getting started

Like healthcare consumers, health plans are entering a new environment in terms of pricing information. That’s why it’s important to engage with strategic partner vendors who can help you reach compliance and strengthen your competitive advantage.

To satisfy the regulation, plans will need strong solutions on the MRF and data side of the regulation as well as the self-service UI. Ensuring the underlying data can be translated and consumed by the user experience will be critical to delivering a usable consumer tool.

Given the complexity of the data, partnering with a vendor to help build out your files, products, services, and other compliance-related initiatives is the first step.

But not every vendor partner is created equal, especially when it comes to MRFs.

Here are a few things to look for:

1. Full MRF creation.

For those who need help with the generation of the Base In-Network MRFs and Base Allowed-Amounts MRFs, you need a vendor partner that can provide project management and project delivery capabilities to actually produce those files.

Make sure their potential in-network MRF scopes include operational readiness, data and contract analysis, transformation logic design, as well as MRF development and configuration. On the out-of-network side, ensure their MRF scopes encompass operational readiness, data review and analysis, and (of course) MRF development and configuration.

2. Web-based file aggregation platform.

For lack of better words, you need an MRF hub. Meaning: you need some sort of purpose-built, self-service, web-based capability to publish and update required files.

This interface must have the capability and bandwidth to conduct network mappings, collect rules and files, host and archive requirements, and download extremely large files.

Before signing on the dotted line, be sure your partner’s SaaS offering is well-situated to help you store, aggregate, generate, and host MRFs. And, perhaps most importantly, streamline the complexity of generating plan-specific MRFs.

3. Rates manager.

You shouldn’t have to develop your own rates-based service offering to deliver local product cost estimates.

A good vendor will give you the tools you need to ingest and manage both your in-network and out-of-network files. A great vendor will take those tools and plug them into a healthcare shopping and transparency platform that meets the data requirements for cost estimations.

Hello, compliance.

4. Data service.

This serves as the beginning of the “cherry on top” of MRF requirements. Let us explain.

The partner you choose should simplify the entire process of handling large files, acquiring and processing your MRF files to a standardized format on a regular cadence. This frees staff to, in turn, focus on the analysis of the data instead of time-consuming file processing and handling.

And although this section is not directly required to comply with either TiC or NSA regulations, this is vital as this is where your direct benefits actualize. The public posting requirement allows both payers and providers unprecedented access to competitive data.

But unlocking this data is not as simple as just downloading massive files. Rather, it involves normalizing files across multiple tables of contents and structuring said data in a more usable columnar format.

Make sure your vendor partner can go above and beyond to support the “cherry on top”.

The wrap up

Both the NSA and TiC final rules will have long-term implications across the healthcare ecosystem. But don’t think of it as just checking a box. These mandates serve as an opportunity to develop solutions that leverage provider and cost data in creative ways – and differentiate your organization from competitors.

Legislation isn’t going anywhere any time soon. Make sure your potential partner has a comprehensive suite of solutions to help ensure current and future requirement compliance.

Interested in how Zelis can help you tackle the pain points of regulation compliance and overall member experience? Check out our latest playbook or connect with us here.