Zelis Price Transparency Solutions

Since the MRFs included every rate, a provider is contracted to perform, they were much larger than anticipated.  This created confusion in the data. For example, fee schedules for multi-specialty practices are often spread across the entire practice, not just for the services specific providers perform, leading to inaccuracies like audiologists being listed as performing knee replacements.  

Additionally, the TiC Rule required every self-funded employer to have its own representation of the data, as each is considered its own plan under ERISA.  

To simplify the data-sharing process, regulators introduced the concept of “tables of contents,” but this also added complexity to file creation, hosting, and maintenance, which must be updated monthly. Partnering with the right vendor to make sure you stay up to date on compliance is key in light of the changing impacts of the regulations. 

While the hosting aspect is mostly settled, some payers struggle with full compliance in creating their MRFs. Issues include integrating carved-out services for chiropractors or behavioral health vendors, and representation of multiple networks within a single MRF, adding complexity.  

Hospital systems have unique situations where they pay themselves differently for their own employees accessing their own system, requiring separate MRFs. This highlights the need for the right partner to help solve these issues and ensure compliance.  

Starting in 2024, transparency data had to be presented to members for shoppable services in individual code sets (i.e. billing codes). This can be confusing for members, as they typically don’t think about accessing healthcare in this way. For example, a member might see that a gastroenterologist is paid $500 for a colonoscopy and think that’s the total cost of the procedure, but that is just a small portion; much of the total cost comes from facility charges, anesthesia, pathology, and other related components. As services become more complex, more actors are involved, which can complicate things further. 

At Zelis, our extensive data and experience have been helping clients achieve compliance from the very beginning. We have successfully implemented 65 payers and counting, ensuring they can rest easy using the Zelis solution. Our services include: 

• The ability to ingest Machine Readable Files (MRFs) per existing regulations and access to comprehensive claims data, allowing us to provide precise pricing information and member out-of-pocket amounts. 
• Our S365 Provider Search solution, which makes it easy for members to access information, including an internet-based, self-service price transparency tool, and other benefits data, through a member-centric platform or via an API that integrates seamlessly with our clients’ UX/UI. 
• Our MRF Creation and Hub, which helps clients manage, aggregate, process, and publish MRFs on a white-labeled website. 

We would love to talk to you about your existing approach to meeting price transparency requirements and how we may be of help. Click here to connect with someone and please sign up for real-time updates and coverage about the regulatory landscape via Zelis’ LinkedIn Legislative Newsletter.