For nearly two years, the healthcare industry has been working toward transparency in coverage mandates. With the  2022 adoption of the Transparency in Coverage rule, machine-readable files (MRFs) containing pricing data are now publicly available.

Transparency in Coverage timeline including release of MRFs

By harnessing this data and turning it into actionable insights, Plans can gain the insights they need to know where they stand in a highly competitive market. Making sense of the data, however, poses many challenges for Plans.  

The Challenge: Buried in Data

The opportunity is significant but getting there isn’t easy. Aggregating, standardizing, and analyzing these volumes of data require advanced data expertise and extraordinary resources. Without the right partner, plans contend with:

    • Massive files containing possibly hundreds of terabytes of data for a single health plan
    • Data redundancy requiring thorough review to ensure quality and accuracy
    • Custom handling leading to high costs to download, process, and host data
    • Limited information with standalone rates and no context

For example, in working with MRFs from major health plans, Blue Health Intelligence® (BHI®) has observed the following:

    • Incomplete published incomplete billing codes (e.g., only publishing ~125 of 700 MS-DRGs). More than 75% of billing codes for one plan are published with modifiers – including Office Visits. 
    • Through Dec. 2022, one plan published files as CSVs (i.e., not a compliant CMS format). 
    • Continued evolution of files, including moving what tables include all billing codes for a network. Several files from one plan in December did not include NPI values (i.e., not CMS compliant). 

The Need: Clarity on the Value of MRF Data

To capitalize on the opportunity provided by MRF data, Plans need to not only compare one rate to another but also understand how files are produced, which negotiation strategies were applied, and how rates apply to plan-specific utilization. The process requires deep data and Plan expertise.

From there, Plans can use the data to understand which employer groups would receive better pricing from a competitor, and how the data can help with client acquisition and retention strategies. They can also uncover insights into which providers offer different pricing to competitors and how pricing varies among competitors. These insights improve negotiations by helping the plan understand how pricing and network products compare to competitors across individual and group markets.

As a member of a provider contracting team, view how your plan weighted utilization and rates vary from competitors to identify the greatest contract opportunities.

Insights that Drive Decisions for Provider Contracting

As a member of a client contracting team, view how your rates vary from competitors to identify the greatest sales negotiation opportunities.

Clear Visibility into Negotiated Rates by Account

The Solution: Transform Data into Insights

Using its deep data and Plan expertise, BHI offers Transparency Analytics to help harness raw data, evaluate it for quality and accuracy, and enable meaningful, informed decision-making. BHI’s Transparency Analytics transforms complex data into simple views, to empower teams with trusted, curated data including service groupings and volume for weighting. With access to competitor pricing, Plans can inform business units, such as provider contracting, sales, and marketing. And plans can accelerate time to insight with self-service reports and filters in a cloud-based workspace using preconfigured Tableau reports.

Ready to improve your competitive positioning? Contact us today to learn more about Transparency Analytics, and request a demo.