The Transparency in Coverage Rule ushers in a new era for payers, providers, and other healthcare stakeholders

A marketplace is purportedly at its “healthiest” when information is available to both buyers and sellers. The Transparency in Coverage Rule (a.k.a. TiC Rule) was designed to ensure a competitive healthcare market by improving healthcare price transparency through the accurate, timely disclosure of information. The ultimate aim is to improve the cost and quality of care by empowering consumers to make educated choices while minimizing government interference in the market (e.g., direct price regulation).

No pain, no gain - Balancing healthcare price transparency mandates with new opportunities

Healthcare price transparency legislation requires payers and providers to take measures to maintain compliance with the Transparency in Coverage Rule, such as publishing contracted rates via machine-readable files (MRFs). Group health plans and issuers of group or individual health insurance (i.e., payers) are also required to supply plan participants with a member shopping tool that provides personalized out-of-pocket cost information and the contracted rates for covered healthcare services and items (read more on that here). 

As organizations work to get up to speed with the compliance requirements, they should be on the lookout for ways to take advantage of the mountain of MRF data available as a result of this legislation. 

Essentially any organization that has a stake in the pricing, provision, or contracting of healthcare services can benefit in some way from MRF insights. Whether you’re a payer, TPA, or self-funded employer trying to optimize network or plan design, a broker or consultant advising clients on benefit plan selection, a provider wanting to set competitive reimbursement rates to attract more patients, or an RCM supporting providers with the payer contracting process, the possibilities are endless.

Market leaders are already exploring how to utilize the rich MRF insights contained within machine-readable files to gather competitive intelligence, conduct comparative benchmarking, inform pricing and reimbursement strategies, and navigate contract negotiations. By choosing the right tool, you can access the treasure trove of MRF data to pull relevant insights that help your organization gain a competitive edge.

How providers can use MRF insights

If you’re a provider, having access to a tool that allows you to easily search, filter, and browse through payer machine-readable files (MRF) can help you size up where you stand in relation to your competition. You can gain clarity on rates within a specific market or where your rates fall relative to your peers that serve the same patient population. 

Here’s a couple examples of the ways providers can take advantage of payer MRFs...

• Access payer-negotiated rates across similar provider specialty groups to set competitive reimbursement rates and optimize revenue management.

• Leverage detailed rate information for negotiations with payers or direct-to-employer group contracting to ensure optimal and fair compensation and reimbursement for services.

MRF insights in action: example use case

Deerhold’s PRIZM Rates product uses search engine technology (Elasticsearch) that enables providers to quickly comb through billions of records to quickly gain useful, relevant market insights.

Let’s say you’re a surgeon performing knee replacements in New York, and you want to understand whether your rates are competitive. Being able to sort by specialty allows the provider to ensure a comparison against similar providers is illustrated. Here’s a clip that demonstrates how you can extract the right insights from MRF data to identify average rates for a knee replacement in your area. 

You’ll want to make sure whatever payer MRF solution you’re using allows you to filter your search by MSA (metropolitan statistical area). In addition, because payer MRFs already contain a ton of data, you should ask your vendor about their process for excluding “junk data” or what’s commonly referred to as “ghost rates” and rates that just aren’t logical, such as contracted rates for a dermatologist performing a knee surgery. 

PRIZM Rates enables you to search for a procedure by the billing code or procedure description. You can choose to narrow your search by geographic region. For example, you can choose to pull up only those records within a specific MSA, such as New York. 

If you provide a very specific service such as knee replacement surgery, you’ll likely want to focus your search to return rates for providers that are the most similar to you. With PRIZM Rates, you can choose to filter your search to high-volume providers, such as providers that perform more than 100 knee surgeries in a given year.

The fun doesn’t stop there: Summarizing MRF search results on the fly with data aggregation

In addition to seeing the detailed MRF records, Deerhold’s data aggregation tool enables you to build on your original search query. You can apply filters to summarize your data on the fly and choose which results you want to view. 

For example, you can select to view the minimum, median, and max rates, the number of billing NPIs, and the count of MRF records. You can then choose to view all this information by carrier, with the option to drill down into the underlying MRF records.

You also have the option to further refine your query. For example, you can choose to bucket search results by carrier and view average rates per TIN to see how you compare against other billing providers.

Data availability isn’t enough

While the Transparency in Coverage Rule is intended to improve healthcare price transparency, requiring organizations to make rates publicly available isn’t enough. Providers and other healthcare stakeholders need to work with a vendor that can help them capture the full benefit of payer MRFs by uncovering MRF insights that are applicable to their unique business.

Deerhold has done the legwork to parse hundreds of billions of records in payer MRFs so users no longer have to comb through ghost rates or unreasonable rates. Deerhold’s unique approach to marrying provider billing data to payer MRF data ensures only plausible records are included to ensure accurate and reasonable reporting.

Deerhold’s PRIZM Rates’s ability to not only produce reports based using payer MRF data but to be able to quickly pivot on the fly shows how it can be a key tool to help providers stay competitive and receive fair reimbursement for services.