Today marks a MAJOR breakthrough in healthcare, but it has nothing to do with cutting edge technology, historic procedures or drug approval. Yet the advancement has the potential to impact care for patients around the country. So what is this massive breakthrough?
Simply put - payer network reimbursement files are now available to the public, cataloging every negotiated rate between every payer and provider in the country. For example, Humana’s reimbursement for HCPCS 76936 (ultrasound guidance of blood vessel repair) is $1,321.59 at Liberty Dayton Medical Center (the first row) - a whopping 4.8x the CMS standard reimbursement rate of $270.29. The other rows listed show various dialysis centers and nursing homes around the country are only reimbursed $179.03 -> $255.76 - all BELOW the CMS standard rate.
Democratizing this information has the power to affect the reimbursement rates hospitals negotiate, and encourage more competition from lower-cost facilities that can provide similar care quality.
The Transparency in Coverage Final Rules set July 1, 2022 as the enforcement date for insurance companies to publish machine-readable files. Unlike with the hospital rollout of price transparency, the big insurance companies have stepped up day one. The TiC Final Rules requires plans and issuers to publish all applicable rates including “negotiated rates, underlying fee schedule rates, or derived amounts” for in-network rates and out of network allowed amounts.
As with the hospital transparency rules, posting files doesn’t necessarily mean ‘compliance’ - we still have quite a bit of work to do to digest the format and see if meaningfully useful price information is included.
Also, compliance doesn’t mean it is easy to obtain and digest the files. Each payer has posted a massive directory of files that are individually enormous. For example, BCBS of Massachusetts in-network pricing data for California spans 25 JSON files of ~25.6GB each. Cigna posted this disclaimer for those attempting to parse their data: ‘Each of the files accessible through the Table of Contents is in JSON format and may be as large as one Terabyte (TB) in file size’. This screenshot shows a sample of Humana’s more than 440k machine-readable files:
Bandwidth charges just to download those files to a cloud storage system will be prohibitive for most firms.
Thankfully, Serif Health has spent months preparing for the size, scale and scope of working with these files. We have developed and defined our data processing tools and we are excited to take on the challenge of extracting payer side data. If you’re a healthcare provider or administrator interested in access to clean, useful in-network reimbursement data, get in touch today for a demo of our price intelligence portal.
If you’re interested in working with healthcare pricing data at this level of scale, reach out to our engineering team - we’re hiring.
Happy Payer Data Day, everyone!
In case you’re interested, here are handy links to several payer MRF sites:
Cigna:
https://www.cigna.com/legal/compliance/machine-readable-files
Humana: https://developers.humana.com/Cost-Transparency
United: https://transparency-in-coverage.uhc.com/
BCBS Examples (Hosted state by state, but with some reciprocity of networks):
https://transparency-in-coverage.bluecrossma.com/
https://pstage.bluecrossnc.com/about-us/policies-and-best-practices/transparency-coverage-mrf
Image credit: 久留米市民(Kurume-Shimin)
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