Cross the bridge to price transparency: Common machine-readable file challenges and lessons learned

What began as a novel concept is now a necessary brick in our path to empowering consumers of healthcare. While we are making strides toward greater price transparency, payers are facing several implementation challenges as they work to meet new regulations. We reviewed some of these challenges in our last blog on the proposed advanced explanation of benefits rule. Building off that, these new transparency requirements CMS mandates payers make their contracted rates publicly available through machine-readable files (MRFs). By providing MRFs, payers enable regulators, legislators, and researchers to access and analyze the data, potentially leading to better understanding of healthcare costs and more informed decision-making.

Payers are also expected to establish an online platform for members, that provides healthcare consumers with meaningful estimates of their healthcare costs. In addition to producing accurate price estimates, these online tools should also be consumer-friendly and accessible.

The combined goal of these new regulations is to increase transparency in cost of care pricing information and enable consumers to make more informed decisions about their healthcare choices as they take on more cost burden. Here are some of our top lessons learned from helping clients navigate the price transparency waters.

Build the foundation

To produce high-quality MRFs, you need to be able to effectively collect, manage, and organize the large volume of complex data needed. But collecting this data is time-consuming and resource-intensive, especially for payers who work with a large number of providers and healthcare organizations.

Digging through dirty data is time-consuming and can result in inaccuracies or compliance issues. Many health plan organizations have struggled consolidating this information and getting it into file formats that are compliant with CMS policies. The result is redundant data that often results in a larger data footprint. Like we’ve seen in the past, new rules and guidance from The Centers for Medicare and Medicaid Services (CMS) often remain in flux for the first couple years of the final rule. MRFs are a new data type and may take organizations a few years to fully embed into their policies and workflows. After the foundation has been laid and data management has been streamlined, it’s time to secure the beams and enhance the quality.

Secure the beams

While this new data type brings innovation to the industry, there are hurdles to conquer first. As mentioned above, having access to a large volume of data is important, but it is fairly useless if the data can’t talk to each other. Most online solutions use claims data to produce estimates, however, CMS has provided additional guidance that requires contracted rates to be part of this equation. MRFs are a vehicle to inject those contracted rates into healthcare service estimation methodology.

With appropriate fields in place , organizations can enable effective data merging and ensure communication across data types. Once you have integrated data, you unlock a whole new world of insights. For example, you could provide more accurate estimates by combining contracted rates, claims data, provider directories, benefits, and more. Integrated data provides researchers and healthcare professionals with advanced insights to help develop more effective programs and improve outcomes.

Lay the bricks

High-quality, integrated data means high-quality, meaningful insights. The consumer experience continues to remain a top priority for payers and these advanced insights continue to drive better care decisions and improved cost management.

Healthcare is complicated and while strides have been made to simplify it, consumers are still forced to juggle a lot of fragmented healthcare services. When patients are making healthcare decisions, trying to find high-quality care while also estimating things like deductibles, cost share, and out-of-pocket maximums can be an overwhelming experience.

It’s important to lay the bricks slowly and strategically, being careful not to overwhelm healthcare consumers more. Price transparency tools will bring a lot of transparency and clarity to the world of medical bills, but there is still so much to consider. Before we load thousands of common services into a price estimator, methodologies, and strategies need to be put in place. Health plans and providers need to find the appropriate balance between level of detail, meaningful insights, and compliance when it comes to shoppable services.

Cross the bridge

The journey to personalized, accurate shoppable services is becoming more of a reality every day. To successfully cross the bridge into this next era of healthcare price transparency, payers need to:

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