New payer price transparency rules take effect Jan. 1

New requirements for payers under CMS' Transparency in Coverage rule take effect Jan. 1.

Since July 1, payers have been required to disclose in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for all covered items and services, and negotiated rates and historical net prices for covered prescription drugs administered by providers.

Starting in 2023, payers must provide an internet-based price comparison tool that allows members to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers for 500 items and services. Price comparison tools must include all services, including prescription drugs, by 2024.

Plans subject to the new rule include individual and group plans (self-insured and level-funded). Those not subject include account-based group plans (HRAs, FSAs, HSAs). Payers not in compliance could face fines of up to $100 per day for each violation and for each individual affected by the violation.

According to AHIP, nearly 94 percent of commercial insurers were already providing their members with online care cost estimator tools as of July.

"For patients, their health insurance providers are the best resource for individualized cost information," the trade group wrote. "While third-party developers may create price transparency apps or tools using this data, they can't deliver accurate, real-time and personalized cost estimates to help consumers make informed decisions."

Since the rule went into effect, the size of the data files being uploaded online by insurers is massive. Third-party developers nationwide have been racing to extract it and launch consumable files and products for healthcare organizations and the public.

"There's trillions of rows of data here that have to be figured out how to be made consumable so that people can make an informed decision," Health Cost Labs founder Leon Wisniewski told Becker's. "Our focus is on understanding how to efficiently extract the data from these files."

Health Cost Labs is a data sourcing company based in Audubon, Pa. Another developer is San Diego-based Turquoise Health, which has been working to aggregate rate records from hospitals since 2020. The company said 78 billion payer price records are now available online from 163 insurers, or around 630 terabytes of data.

In October, Turquoise said it expects the first tools using payer data to become available in early 2023. 

More details from CMS about 2023 price transparency requirements are available here.




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