What is Payer Price Transparency?
The Centers for Medicare and Medicaid Services (CMS) require all commercial payers, under the Payer Price Transparency mandate—the Transparency in Coverage (TiC) Act—to disclose their negotiated rates for specific billing codes and providers.
While this rule applies broadly to commercial payers, it exempts Medicare Advantage and Managed Medicaid plans, which CMS does not require to publish their rates.
Note: This transparency requirement is specific to medical claims and excludes pharmacy and National Drug Code (NDC) claims.
When did Payer Price Transparency go into effect?
November 2020
Transparency in Coverage Rule finalized, requiring machine-readable files (MRFs) with in-network rates and out-of-network charges.
July 2022
Group Health plans and insurers began posting MRFs with pricing information for covered items and services.
January 2023
Price transparency is required for 500 shoppable items and services.
January 2024
Price transparency expands to include all covered items, services, and drugs.
What is the Purpose of the Health Plan Price Transparency Act?
The Health Plan Price Transparency Act aims to empower consumers by providing clear cost information for covered items or services before they receive care.
This act mandates that health plans publicly disclose detailed pricing data—such as cost-sharing amounts and in-network negotiated rates—in machine-readable files that are updated monthly. This transparency helps consumers make more informed healthcare decisions and anticipate out-of-pocket expenses.
Who is Affected by Payer Price Transparency?
Payers
This increased transparency represents a considerable shift for payers, as their pricing structures and negotiated agreements are now publicly available. As mentioned in the section above, the TiC Act aims to provide patients and providers with the tools to better understand and compare costs. This requirement introduces new mandates for payers but sets the stage for a more informed and competitive healthcare marketplace.
Patients
With greater price transparency, patients can make more informed decisions about their care, understanding potential costs upfront. This clarity allows them to plan financially and select treatments that align with their health needs and budget, ultimately leading to a more empowered and proactive healthcare experience.
HME and Infusion Organizations
For HME and infusion providers, access to pricing data allows them to gain visibility into rates for all payers, which could give them leverage when negotiating contracts. However, even though this information is publicly available, the data in its raw format requires considerable time and effort to translate into digestible insights.
Trella Health and Transparency into Payer Rates
To address the challenge organizations face in compiling and understanding the massive amounts of data available, Trella Health launched its Commercial Payer Rates Data solution, which presents the data in a clear and straightforward format.
With visibility into the rates of over 10,000 insurance plans covering over 3.5 million healthcare providers and organizations, Trella’s Payer Rates data gives HME and Infusion organizations unmatched insights into commercial payer rates across the United States.
Trella Health’s Payer Rates solution delivers real-world applications that organizations can use to create a tangible impact, such as:
- Negotiating Competitive Rates: Identify payers with pricing gaps and compare rates with competitors in similar categories.
- Identifying New Contract Opportunities: Discover payers in your state or market offering favorable service rates.
- Broadening Product Offerings: Find additional products that complement your existing contracts.
- Expanding into New Markets: Assess rates and competition in new regions to inform expansion.
- Evaluating Acquisition Opportunities: Evaluate potential acquisition targets based on their existing rates and competitive positioning.
Trella Health’s Commercial Payer Rates Data solution empowers HME and Infusion organizations to navigate the complexities of payer contracts confidently. By transforming large amounts of machine-readable file data into digestible insights, this solution enables organizations to make informed decisions that drive strategic growth and strengthen their position in payer negotiations.
With Trella’s data-driven approach, you can approach every conversation with clarity, confidence, and a competitive edge.
To learn more about Trella’s Payer Rates solution and how we can help you strengthen your positioning with payers, request a personalized demo today.
Resources
https://www.cms.gov/priorities/key-initiatives/healthplan-price-transparency
https://www.uhc.com/united-for-reform/health-reform-provisions/transparency-in-coverage-rule
