The healthcare domain is undergoing a seismic transformation. This shift, driven primarily by regulations like the No Surprises Act (NSA) and Transparency in Coverage (TiC) rule, focuses on empowering consumers to make well-informed choices about their healthcare journey.

Larry West, Zelis Chief Data Intelligence Officer, recently sat down with Future Healthcare Today to delve into the profound implications of these regulations and how they’re instigating innovative solutions to aid consumers, providers, and payers in navigating the increasingly complex healthcare landscape.

As always, we’ll share an overview below, but you can also listen to the full podcast here:

Cracking the code on TiC regulations

The TiC final rule, released by the Department of Health and Human Services (HHS) in late 2020, aims to empower consumers to make informed healthcare decisions. Traditionally, consumers were often left in the dark about their medical expenses until after the care was received, resulting in rising medical bills. The root cause? Concealed negotiated rates that were inaccessible to the general public.

To address this issue, the TiC rule requires plans and issuers offering health insurance coverage in the individual and group markets to disseminate negotiated contract rates data through machine-readable files (MRFs). These files are made available on publicly accessible websites, in theory to enable consumers to compare medical service prices before undergoing care. MRFs encompass in-network rate files and allowed amount files, each catering to distinct aspects of healthcare cost assessment.

This so-called transparency should empower members to make informed decisions about their healthcare journey, understanding both contract rates and their personal financial responsibility before receiving medical services, but that’s easier said than done.

MRFs contain data encompassing a payer’s entire contracted rate set for in-network providers. Meaning: due to sheer size and complexity, the data within MRFs are not actually readily usable for consumers.

But despite the vast data available, you still can’t get a full picture with an MRF alone. In order to fully use the information in MRFs, you must complement it with other provider demographic information, such as names, specialties, addresses, and affiliations.

And that’s just the beginning of the challenges. To dive deeper into the challenges of MRFs, read our recent blog, Transforming Healthcare Transparency with Payer MRFs.

Unveiling the overarching impact

From the consumer standpoint, the transparency regulations aim to offer a comprehensive view of healthcare prices as has never been done before. However, as mentioned briefly above, quite a few complexities have arisen.

On the health plan side, these regulations have paved the way for innovation.

Previously, organizations relied on market basket data, clearinghouse service data, coordination of benefits (COB) data, and assumptions to understand competitors’ pricing. With MRFs, this information becomes publicly available in a more usable and actionable format, revolutionizing how businesses evaluate pricing strategies, drive reimbursement rates, and gain a competitive edge.

As such, payers now possess an opportunity to leverage this newly accessible data to craft advanced analytical tools that can influence various aspects of operations, from contracting to strategy development.

Provider vs payer transparency data

There are significant differences between provider and payer data, primarily in terms of their structure and adherence to compliance requirements.

Provider data lacks standardization, leading to inconsistent delivery, especially in areas like episodes of care and price interpretation. In contrast, payer data currently benefits from a clear schema definition set by the CMS, creating a line of consistency across all payers.

Providers have struggled with widespread non-compliance, with only a small percentage providing complete and clear price information. Recent actions by the CMS, including warnings and corrective action requests, highlight the challenges in ensuring hospitals meet transparency regulations. On the payer side, it’s too early to gauge full adherence, but there’s a notable commitment to meeting these mandates among payers.

Bottom line: while provider data may not be comprehensive just yet, the evolving approach of payers shows promise for improved transparency across the healthcare market.

The wrap up

Regulations like NSA and TiC are ushering in a new era for the healthcare industry. By illuminating healthcare costs and empowering consumers, these regulations continue to foster innovation while reshaping the healthcare journey.

Luckily, Zelis can be a guiding light for your organization during these unprecedented times. Learn more here.