Welcome Serif Health readers new and old! We are excited to continue sharing how Serif Health customers have effectively used price transparency machine readable file (MRF) for many different use cases.
As healthcare costs continue to rise, new health plans have started to emerge focused on effectively using technology and data to lower the cost of care for self-funded employers, with small and medium-sized businesses increasingly interested in self-funded insurance options where the firms pay for healthcare from their own funds for workers rather than by purchasing health insurance. In their 2023 Employer Health Benefits Survey, the Kaiser Family Foundation reported that 18% of employees at small firms (less than 200 employees) and 83% of employees at large firms (greater than 200 employees) were enrolled in self-funded plans in 2023. New health plans and self-funded employers can use the price transparency data in a myriad of ways.
Building Preferred Provider Networks
Part of the core value proposition of newer health plans is the ability to effectively reduce costs for the employer, especially through steering patients to preferred high quality providers and facilities with relatively low reimbursement rates.
So how can this be done effectively? The most straightforward way is for a plan to build its own provider network and negotiate with them directly to determine reimbursement rates and fee schedules for various procedures and services. This is where price transparency data can be a key strategic asset for any health plan.
Instead of relying on general market benchmarks like a percentage of Medicare for the region or extremely expensive and messy claims data, the price transparency data that is now available enables any health plan to understand the existing commercial reimbursement rates a provider has with existing plans where they are in-network. With specific price intelligence, new and growing health plans can now be extremely strategic about which providers they choose to bring into their network and more effectively negotiate reimbursement rates in a dynamic way. With price transparency tools, this more nuanced understanding of market reimbursement rates can lead the way for new plans to build more innovative value-based contracts and benefit design for their providers and members.
However, many plans starting off don’t have the capacity to build their own provider network immediately. Most have to lease or use networks from more established carriers (e.g, Cigna) or rental networks (e.g., First Health). Even with a leased network, access to price transparency data products and analytics can be invaluable. With price transparency data, plans can evaluate the carrier networks and their reimbursement rates down to the specific provider and code level to identify the best low-cost providers as “preferred providers'' for steering patients for a specific specialty or even procedure. Care navigators can actively guide patients toward these preferred providers or benefits can be designed by the plan (e.g., lower copays) to incentivize patients to choose the preferred providers.
Demonstrate Savings and ROI for Employers
Moreover, with access to price transparency products like Serif Health’s, new plans can show existing and potential customers a crystal clear view of the savings they generate. Plans working with Serif Health do this in a variety of ways. Some are comparing the claims of their preferred providers to the machine readable file prices of those same providers with other carriers and networks, while others who are steering patients within rental networks are comparing the claims of their preferred providers to the median or region’s dominant health system’s machine readable file prices within the same network.
New health plans and TPAs are using their edge in technology to present a compelling new option for self-funded employers and patients at large, and we are extremely excited about the potential for price transparency data to play a major role in helping them succeed.
If you are new plan interested in Serif Health’s price transparency data offerings, please reach out: https://calendly.com/serif-health
