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The Payer Federal Price Transparency Rule: Overcoming Data Challenges


Author: Maria Nikol, MJ


Following July 1, 2022, most group health plans and issuers of group or individual health insurance across the country are required to disclose pricing information of negotiated rates for healthcare services between insurer and provider under the new Federal Price Transparency Rule (The Rule). The stated purpose of The Rule is to “empowering consumers with the necessary information to make informed health care decisions.”

The information is to be rolled out in 3 stages: 

Stage 1: Machine-Readable Files containing the costs for items and services related to in-network rates and allowed amounts. 

Stage 2: Internet-based price comparison tool (also available by phone, or in paper form, upon request) allowing an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers by January 1, 2023. 

Stage 3: Internet-based price comparison tool (or disclosure on paper, upon request) allowing an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or group of providers, for all items and services by 2024. 

The information is currently available via Machine-Readable Files (MRFs), following a CMS-approved schema. Beginning July 1, 2022, CMS began to enforce applicable price transparency requirements upon insurers, including requiring corrective actions and/or imposing a civil money penalty up to $100 per day, adjusted annually for each violation and for each individual affected by the violation.

However, for anyone that has worked with commercial payer data in the past, you’ll know that payer data can be very complicated and challenging to decipher. While health plans are required to comply with these rules, and each health plan that we evaluated is narrowly compliant with the law, there is a lot of room for growth to achieve the spirit of the law.  This is especially the case given that almost all the publicly facing machine readable files are precisely just that; only readable by a machine.

Below, you will find a summary of our findings and perceived challenges, which which will resonate with those of you who have worked with CCLF files from commercial payers. 

MRFs

As the name would suggest, these files must be machine readable. If a consumer goes to the health plan website to download the files, they are able to do so. In fact, I encourage you to try it! However, the download that you receive is complete nonsense to a human eye. Thus, you will need an extremely technical person and process to be able to work with these files. In fact, only a few organizations were able to ever parse this data, including Revelar Analytics. Many value-based care organizations will find this challenge familiar: receiving a multitude of files on a monthly basis from insurance companies and hoping to identify areas of opportunity from millions of CCLF files. 

MRFs are HUGE

Once you’re able to open each file and make sense of it, you’ll immediately notice that you have a massive storage issue. Each file of procedural rate codes often equates to gigabytes worth of data which may not even load within the memory of a typical consumer computer. Revelar Analytics has decided to partner with Amazon Web Services (AWS) to alleviate these storage and compute issues. 

CMS-approved schema

While there is a CMS-approved schema, and each health plan is expected to comply with the requirements, you’ll immediately notice that the data is not actually provided in a uniform file format. This is very common for commercial health plan data. These challenges are often seen within performance analytics systems that look to utilize and leverage claims data. This challenge can be overcome by developing a proprietary single schema that helps to make this data uniform and ultimately more manageable. Having technology which conforms data to a single schema makes it possible to do an apples-to-apples comparison across payers.

Large Payer Data by EIN 

Many of the large payers provide not just a single MRF, but rather hundreds of MRFs which must be searched, sorted and filtered by EIN. This creates significant confusion regarding which files to review and compile. 

Data Updates 

Each payer, similar as to claims files, updates the data at their own frequency. Some payers have decided to update these files on a daily basis, resulting in 365 versions of the same file annually. 

Working with this data…

While it is exciting that this data is now technically available, bringing us one step closer towards price transparency, there is still a long way to go to truly achieve the goal of “making pricing information available and understandable to the public.”

Revelar Analytics has been able to solve for some of the deep technical challenges that we’ve noted above, given our expertise and years of industry experience. Contact us today to learn more about working with us to help your organization derive actionable insights from machine-readable commercial payer files. 



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