Nexsen Pruet Health Care attorney Matthew Roberts was recently quoted in an article for Health Payer Specialist. 

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Payers See Path to Better Price Transparency

By Gale Scott, Vrushank Nayak July 11, 2022

Posting prices that only computers can read doesn’t help consumers much, but many payers are taking the initiative to post usable price data.

Payers generally appear to have met the July 1 federal deadline for posting price information on their websites. But several payers agree with critics that price data in the form currently required by the new federal Transparency in Coverage rules is not consumer-friendly. Many are pledging to take further steps–including contracting with third party tech services that clarify the data– so members and comparison shoppers can get information they can actually use.

The issue came to attention when the first phase of the new federal transparency rules for health insurers went into effect July 1.
Now most group plans and issuers of group or individual health insurance are required to disclose in-network rates and allowed amounts paid to out-of-network providers. The transparency rule does not apply to Medicaid and Medicare Advantage plans. The mandate is similar to one for hospitals that took effect last year.

The hospital rollout did not go smoothly, with just 14% of hospitals meeting the initial deadline. “I’m anticipating there will be a little bit better compliance with insurers," says Matthew Roberts, Health Care and Public Policy Practice Group Leader at the Nexsen Pruet law firm’s Columbia, S.C. office. “At the minimum, they’ve got to have a machine-readable file of in-network rates for all covered services," Roberts says. “The real question is, is this information something the average person can easily access and understand.”

It’s not, an Aetna spokesperson says: “The files were not designed by the government to serve as member transparency tools,” adding that Aetna will have a new cost-estimator tool available for members in January. Aetna is based in Hartford, Ct.

Meanwhile, plan members can use other price transparency tools the company provides on its website and through mobile apps, or call its member services department with questions.

Centene's site has a link to data for its individual market and commercial lines of business, but also agrees the collections of data aren’t in a form useful to members. “These are large files that may not be as directly useful for members. Members may want to access their health plan coverage materials instead to learn more about their benefits,” the website post notes. Centene is based in St. Louis, Mo.

At the Blue Cross Blue Shield Association in Chicago, Ill., a spokeswoman said its affiliated companies have met the deadline for posting the machine-readable files but intend to take the rule further.
“Machine-readable files are not a consumer-friendly solution and will not help members better understand the cost of their health care services. That is why BCBS companies stay focused on developing tools that help people easily access and compare out-of-pocket costs, doctors’ ratings and reviews as well as know if their preferred health care provider is in-network, without hassle.”

A spokesperson at Health Care Service Corp., a Blue Cross Blue Shield Association licensee in Chicago, offered a similar statement. Since the average consumer has no way of accessing the machine-readable files, “We offer our members a growing number of user-friendly tools that provide cost and quality information they can use to make decisions that are right for themselves and their families."

Roberts says the disconnect between meeting the letter of the new transparency rule and its larger purpose of helping consumers shop for lower price care is creating a new and lucrative niche for tech companies. “Third parties like Turquoise Health and others are coming in, tech companies that have a very easy way to aggregate the data and sell it back to insurers–more entrepreneurial ones are giving it to consumers in more usable form.” Turquoise has hospital clients that use its software to meet the CMS transparency rules in a user-friendly format.

The big question as the transparency rules take effect through 2024, is what the impact will be on negotiations between payers and providers. Both groups fought the transparency rules saying they are anti-competitive. “I’m not sure we’ve started to see the impact,” says Roberts. “But it’s inevitable they would happen; it’s been a bipartisan issue and people feel it’s a good idea.”

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