The Consolidated Appropriations Act of 2021 (the Act) was passed to increase price transparency in the healthcare system and to empower patients to make more informed decisions about their care. The US Department of Health and Human Services through its Centers for Medicare and Medicaid Services (CMS) implemented the Act via rules and regulations related to Hospital Price Transparency (HPT) and Transparency in Coverage (TiC). Hospital Price Transparency requires the online posting of machine-readable files (mrfs) for hospitals and Transparency in Coverage requires the online posting of mrfs by health plans.
Hospital Price Transparency
For HPT, Hospitals are required to post mrfs every year. These files must include chargemaster level detail for gross charges as well as payer-specific negotiated payment rates. In addition they must also conform to a specific schema, published by CMS. The above is all positive news for an industry that has historically been bogged down by opaque pricing practices.
However, there are thousands of these files, and even with the enforced schema, they come in many different stages of completeness, making it a challenge to draw any meaningful insights.
Transparency in Coverage
For TiC, Health plans, including insurance carriers, TPAs and self-insured employers are required to post mrfs every month. These files must include in-network negotiated rates for all providers they contract with, as well as historical out of network rates that they have paid. Similar to the HPT mrfs, the TiC mrfs are required to follow a schema designed by CMS. TiC, with all the information it provides, is a massive win for the industry. Everyone from patients, to employers to providers can benefit from the information provided.
However, just like the HPT mrfs, there are some roadblocks. The TiC files are massive, with some larger than 100GB. This means that they won’t open on most desktops and need specialized processes to read. Also, the schema, while good for enforcing uniformity, is meant to be readable by computer programs and not humans. So again, special software is required to derive any benefits. That’s where we comes in.
With the price transparency data obscured by the above mentioned roadblocks, Symmetric Information is ready help you unlock its potential. Symmetric information, using techniques at the forefront of data science, processes these revolutionary transparency data. It then combines them with provider quality data, and employer health care claims, creating its SI Platform, a national ‘best practice’ repository, modeling platform, and hub.
This platform is specifically designed to empower employers to take back control of their employees’ healthcare, reducing their cost exposure, while helping their employees access more affordable, higher-quality care.