Choosing the right partner for MRF compliance

The Transparency in Coverage (TiC) final rule went into effect July 1, 2022, and requires insurers to include provider-negotiated rates, as well as allowed billable amounts for all out-of-network providers. 

Given the complexity, compliance continues to be complicated and costly for payers.

Enter Machine-Readable Files (MRF) 

The TiC rules require providers to ultimately publish standard charges in a consumer-friendly format.

An MRF, or Machine-Readable File, is a digital representation of data or information in a file that can be imported or read by a computer system for further processing. To satisfy the regulation, these files must be produced in a specific CMS-defined format, called JSON, and are not meant for direct consumption by a consumer. Rather, they are meant to provide a common data framework that, in turn, enables consumer-facing tools to display accurate cost information.

Let us explain. 

If you contract your own network, you’re obligated to create an MRF file. If you rent, you’ll be given this file. On its own, however, said file isn’t enough to derive cost information; your MRF data needs to be augmented.

MRF files must be adjusted to include all client Employer Identification Numbers in a new MRF file. The file should also represent your highest numbers, to the extent that you have insured plan offerings, as well as plan names.

Your data must also be combined with a presence of historical claims data to match the MRF cost data to services that are actually performed by providers.  

With all the underlying MRF data required for your membership in hand, the crucial last step to compliance is displaying the transparent cost data in a user experience that is useful and helpful to the member.

Getting started 

Health plans are entering a new environment in terms of pricing information. That’s why it’s important to engage with strategic partner vendors who can help you reach compliance and strengthen your competitive advantage.  

Given the complexity of the data, partnering with a vendor to help build out your files, products, services, and other compliance-related initiatives is the first step. 

But not every vendor partner is created equal. Here are a few things to look for: 

1.  Full MRF creation. 

For help with the generation of the Base In-Network MRFs and Base Allowed-Amounts MRFs, an ideal vendor partner can provide project management and project delivery capabilities to actually produce those files.

Make sure their potential in-network MRF scopes include operational readiness, data and contract analysis, transformation logic design, as well as MRF development and configuration. On the out-of-network side, ensure their MRF scopes encompass operational readiness, data review and analysis, and (of course) MRF development and configuration.  

2. Web-based file aggregation platform. 

Ultimately, you need an MRF hub. Meaning: you need some sort of purpose-built, self-service, web-based capability to publish and update required files. 

This interface must have the capability and bandwidth to conduct network mappings, collect rules and files, host and archive requirements, and download extremely large files. 

Before signing on the dotted line, be sure your partner’s SaaS offering is well-situated to help you store, aggregate, generate, and host MRFs. And, perhaps most importantly, streamline the complexity of generating plan-specific MRFs.  

3. Rates manager. 

You shouldn’t have to develop your own rates-based service offering to deliver local product cost estimates.  

A good vendor will give you the tools you need to ingest and manage both your in-network and out-of-network files. A great vendor will take those tools and plug them into a healthcare shopping and transparency platform that meets the data requirements for cost estimations.  

4. Data service. 

With data service, your vendor partner can go above and beyond supporting MRF compliance.

Your vendor should simplify the entire process of handling large files, acquiring and processing your MRF files to a standardized format on a regular cadence. This frees staff to, in turn, focus on the analysis of the data instead of time-consuming file processing and handling.

Although it’s not required to comply with regulations, data service is vital as this is where your direct benefits actualize. The public posting requirement allows both payers and providers unprecedented access to competitive data. 

Unlocking this data is not as simple as just downloading massive files. It involves normalizing files across multiple tables of contents and structuring said data in a more usable columnar format.  

Conclusions

Both the NSA and TiC final rules will have long-term implications across the healthcare ecosystem. Beyond just checking a box, these mandates serve as an opportunity to develop solutions that leverage provider and cost data in creative ways – and differentiate your organization from competitors. For more information, check out our transparency playbook here

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