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 a recent podcast, Sapphire Digital SVP of Sales Dennis Charland sat down with Future Healthcare Today’s Matt Lang to provide a closer look at what the Transparency in Coverage (TiC) final rule means for payers and explore solutions to ensure compliance.

As always, we’ll discuss the highlights below, but you can listen to the full podcast here:

A Bit of Background

During October 2020, HHS and the Departments of Labor and Treasury finalized the Transparency in Coverage final rule.

The TiC final rule requires payers in both individual and group commercial markets to disclose cost-sharing estimates and additional content to enrollees upon request and to publicly post negotiated in-network provider rates, historical out-of-network allowed amounts and billed charges, and drug pricing information.

Serving as the latest piece in a number of Administration efforts to increase price transparency for healthcare services, the rule aims to empower consumers to make informed decisions and foster price competition while driving costs down in the commercial market.

In fact, the delivery of the final rule has been described as historic.

But why?

It may be due, in part, to the convergence of two major pieces of regulation — Transparency in Coverage (TiC) and the No Surprises Act (NSA). Both of which focus on bringing down the cost of healthcare. But the rule also really digs into the secret sauce of payers (aka contracted rates with providers), and with its sheer size and notoriously tight deadlines, there’s no doubt something important is brewing.

Payer Requirements

One of the key components of the TiC final rule is the requirement for payers offering non-grandfathered coverage in the group and individual markets to disclose, on a public website, information regarding in-network rates for covered items and services in machine-readable files.

Meaning: service rates must be displayed in a machine-readable format, updated monthly, with free and unfettered access.

Moreover, a member-facing digital tool must be made available to cover the 500 shoppable services 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.

Meeting Compliance

Baby steps.

It all starts with the creation of the MRF file.

If you contract your own network, you’re obligated to create an MRF file. If you rent, you’ll be given this file. But on its own, that’s not actually enough to derive cost information to display to members.

Rather, those MRF files must be adjusted to include all client Employer Identification Numbers. 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.

But it’s not that easy.

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

The last step is displaying the data in a user experience that is useful and helpful to the member. That’s the key.

Buy One, Get One

Meeting the TiC rule helps payers come into compliance with portions of the No Surprises Act.

The most significant connection boils down to the internet-based tool.

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.

Advanced EOBs also come into play.

It’s pre-service, so either the provider or the member can submit the list of service codes needed by the providers performing services to get a pre-treatment estimate for how much that service will cost.

Simply put, both acts make a strong push for upfront communication regarding cost of services.

Payer Benefits

Within the realm of member experience, these regulations present payers with a real opportunity to differentiate themselves.

If a payer can provide more information on where members can receive the best care, they can demonstrate the total cost of care differential, an advantage in the market over competitors and drive a truly positive member experience.

Happy members equal lower claim costs equal high health outcomes. Win. Win. Win.

The Wrap Up

While the government is likely to continue issuing additional guidance, these regulations should be viewed as stepping stones towards a better healthcare experience for us all.

Interested in finding out how Zelis can help your organization reach compliance and beyond? Connect with us.