Happy February all! Our processing notes for February are quite interesting, and will focus on just one topic - UnitedHealthcare's TiC postings and the idea of meaningful compliance.
One of the prevailing assumptions with the Transparency in Coverage Act’s implementation is that most payers have been and continue to be fully compliant from day one. Key word to debate there is ‘fully’.
Yes, the majority of payors made files available on day one, and yes, those files largely followed the schema defined by CMS. But ‘full’ compliance would indicate that all relevant codes and prices are posted for all in-network providers.
What we’re starting to see for a handful of payers is a lower and lower percentage of providers in the files having in-network rates associated.
Our deep dive for this month’s post: UnitedHealthcare.
UnitedHealthcare posts their TiC data at their directory website in files that represent their branded nationwide networks, indicated by letter codes. For example, the United “Choice” network TIC post primarily consists of the C0 file, “Navigate” is the S9 file or S8 file plus the P3 file, “Choice Plus” is C2 and P3, so on and so forth.
Serif Health has developed quality gates to score each data file from each payer each month, in order to track data quality, ensure the data volume matches the supposed side of the provider networks, and identify regressions in data quality over time.
For this post, we'll look at one particular network file over time - the "P3" provider network file. This file is part of their Choice and PPO networks, and contains a massive number of providers. It represents an important chunk of UHC's provider network.
In our November post, we noticed a reduction in the P3 network file size. We scanned the files with our tools at the time, and the metrics we were analyzing didn't substantially change. Given these metrics, we gave UHC benefit of the doubt. Our assumption was that they improved compression rates or perhaps reduced the amount of redundant or ‘zombie’ data (codes that were reported but not actually billable in the real world) in the files.
In full transparency, that assumption was a mistake, and we should have dug deeper. We further enhanced our scanning tools and discovered the underlying references used in the "in_network" prices section of the MRF file - that is, the count of the in network providers listed in the MRF posting that actually have a price associated with them - has been substantially reduced month over month.
Said another way, large reductions in data volume and data completeness have occurred in UHC’s files since their initial postings in July and August.
Here’s the extended quality and structure metrics we extracted from United Healthcare’s P3 network postings from August 2022, January 2023, and February 2023:
Practically, what this means for patients, consumers, and TPAs who rely on this information to administer benefits and shop for care is that United Healthcare has removed 92% of their in-network provider rates from their transparency postings, making it less and less likely that the MRF data can be used to locate rates, compare networks, or price and shop for care.
As a concrete example, let’s zoom in on Physical Therapists, NUCC taxonomy code 225100000X. A typical PT billing code is 97110. If we run our extractor on the P3 file from each of these months filtered down by that taxonomy and billing code we get the following results:
To close the loop and confirm these data gaps aren't intentional - that is, this isn't the result of providers being moved out of the network - let's do a provider lookup on UHC's own in-network provider tools on a randomly selected provider NPI that appears in August but not in January or February. Provider NPI 1316077308 (A physical therapist located in Hicksville, NY) is listed with a rate of $26.69 for CPT® code 97110 in the August UHC file, but no rates were available for this NPI in UHC's January or February file.
When we search UHC’s provider directory (more specific link we used here), we find that this provider is indeed still in network with UHC, in Navigate, Choice, and Options PPO networks:
The ultimate takeaway here is that UnitedHealthcare is not including rate data for all of their in-network providers in their latest TiC postings, which implies they are not fully compliant with the law. For a common TiC data use case, we are able to locate 70% fewer in-network providers' rate data in February compared to August. This reduction in size isn’t just occurring in the P3 network - it’s happened in every nationwide network file posted by UHC.
We reached out to UHC with these findings and got no comment or response from their PR team.
In summary, the idea that ‘full’ payer compliance has been achieved should be revisited by all industry participants and by regulators. Even if voluminous, a posting may not necessarily be complete. We need to do more than just validate basic schema compliance - regulators should be counting and tracking the number of negotiated rates quoted for relevant providers inside of each MRF file, to hold payers who generate MRFs accountable for reporting rates for all in-network provider participants.
For consumers of the machine readable file data - if you’re looking for an MRF data processing partner who can do this analysis and give you transparent metrics on network-by-network MRF data quality, get in touch with us today!
For those looking to repeat or verify this analysis, the august file URL used for this analysis has been archived by UHC. A cached copy is available from Serif Health below.
UHC August 2022 P3 MRF File (Serif Health Cached Copy)