Enhancing Healthcare Pricing Transparency: Proposed Regulatory Changes

Efforts to enhance healthcare pricing transparency are gaining momentum with new proposed amendments to payer price transparency guidelines. The Centers for Medicare & Medicaid Services, Department of Labor, and Department of the Treasury aim to improve clarity, accuracy, and standardization of pricing disclosures from non-grandfathered group health plans and health insurance providers. This initiative builds upon the Transparency in Coverage rules established in 2020.

Proposed Regulatory Changes

Detailed in the Transparency in Coverage proposed rule (CMS-9882-P), the new regulations highlight several revisions to the current framework. Existing requirements compel non-grandfathered group health plans and health insurance carriers to publish machine-readable files monthly. These files include In-network Rate Files, Allowed Amount Files, and prescription drug data, aiding in comprehensive price transparency.

Challenges and Solutions

Regulatory departments recognized challenges, such as unwieldy file sizes and inconsistencies with the Hospital Price Transparency rule, after reviewing past implementations. The proposed amendments suggest reducing file sizes by eliminating unlikely provider-rate combinations, publishing internal provider taxonomy mappings, and introducing a Utilization File listing recent claim-processing providers.

Standardization and Simplification

Another significant proposal aims to standardize reporting at the provider network level rather than by each plan, reducing data volume. This adjustment aligns with hospital data reporting practices, enhancing consistency and user-friendliness. The proposed rules also lower the claims threshold for out-of-network reporting, extending the reporting period, and including elements like plan types and enrollment.

Emphasizing User Accessibility

To improve data accessibility, the amendments ensure navigation pathways on payer websites and establish contact points for inquiries. They recommend quarterly updates of in-network and allowed amount files, easing data management burdens and reflecting actual provider rate changes. Industry stakeholders are invited to comment on adopting a consistent file format, considering JSON and CSV.

Future Integration and Implementation

These proposed changes, if approved, would take effect for plan years starting January 1, 2027. They represent a move towards greater transparency and utility in healthcare pricing, enabling informed decision-making for plan participants and beneficiaries. The rules also synchronize with the No Surprises Act, mandating accessible cost-sharing data and comprehensive consumer support via phone channels.