CMS shared its Transparency in Coverage rulemaking — formed in partnership with the Labor and Treasury departments — on Oct. 5. Now, payers are reckoning with the changes.
The rule updated previous regulations introduced by the Trump administration in 2020, such as a requirement for payers to post negotiated rates. The recent rule cuts so-called “ghost rates” from payers’ in-network rate files, increases out-of-network price disclosures and calls for executives to attest to their data accuracy. Hospitals have generally responded favorably to the rule, saying that there is now more parity between insurers and providers.
Patrick Quigley, executive chair and co-founder of Sidecar Health, told Becker’s that insurers’ published information has historically been challenging to unpack, and the company pulls insurer price files into its pricing model. The elimination of “ghost rates,” or rates for services that providers would not be likely to offer, is one major step toward alleviating those challenges.
“We don’t need to know what a heart transplant from a podiatrist costs since they’re not doing them,” Mr. Quigley said. “This allows us to get closer to the point of empowering people to make decisions in their healthcare with knowledge, which we think is critical to controlling costs in the U.S. healthcare system.”
Mr. Quigley said, under the rule, payers also will need to be “more specific about how costs are explained by network.” The regulations require payers to post one in-network rate file per provider network, rather than one per plan.
Heather Thiltgen, president of Presbyterian Health Plan, specifically mentioned one lift for her team: personalized care estimates accessible by phone. This requirement needs to be fulfilled by 2027, building on the already-required online and paper options.
“You think about the operational implications of that. [Someone] calls up; we need to be able to tell [them] specifically what this service might cost,” she said. “Making sure that’s omni-channel is a lift for us, and I think it’s an important direction that we would want to go as an organization, regardless of the new regulations.”
She said, despite an overall desire for more transparency, the health plan has to balance limited resources and consider state-level requirements, as well.
Mr. Quigley said the rule marks “another huge milestone” for healthcare to be “shoppable.” Rather than using traditional provider networks, Sidecar focuses on how members spend their healthcare dollars. Sidecar’s app lists prices to inform member behavior. Mr. Quigley said legacy carriers have the ability to adopt and further embrace transparency and shoppability, as well, rather than just comply with the regulations.
“Frankly, large health plans don’t need to wait for more regulation to use the information they are now required to publish in a meaningful way,” he said. “They can actually embrace that information that they’re publishing and make it available for their members in a digestible way, so they can make decisions.”
Mr. Quigley compared the situation to building a strong foundation for a house, but something should be built on top.
“We’re going to want to see structure coming out from the foundation of this data to enable people to start making good decisions,” he said.
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