Remember that long movie with barely any dialogue that made you scared of Siri and Alexa (at first)? You probably didn’t watch it, but you know about H.A.L 9000 and the black slab monolith that does all the fancy science fiction stuff.
The machine-readable files (MRFs) released by hospitals in 2021 and payers in 2022 are that same monolith. Even more recently, Georgetown said you’d need a supercomputer (not as cool as the monolith) to access these files. The good news is you don’t need a supercomputer to get access to pricing data. The bad news is sorting through how to buy this data is confusing.
We’ve built a guide to help as you consider purchasing and using this new category of healthcare data.
Claims, MRFs, and Schemas, oh my!
It’s always good to start by getting on the same page, so let’s define the phrase “price transparency data,” which is becoming a buzzphrase.
A brief history lesson: in the Hospital Final Rule, which went into effect 1/1/21, CMS first introduced the concept of five types of Standard Charges:
- Gross charge: the charge for an individual item or service that is reflected on a hospital’s chargemaster, absent any discounts
- Discounted cash price: the charge that applies to an individual who pays cash, or cash equivalent, for a hospital item or service
- Payer-specific negotiated charge: the charge that a hospital has negotiated with a third-party payer for an item or service (emphasis added)
- De-identified minimum negotiated charge: the lowest charge that a hospital has negotiated with all third-party payers for an item or service
- De-identified maximum negotiated charge: the highest charge that a hospital has negotiated with all third-party payers for an item or service
Next, Transparency in Coverage went into effect on 7/1/22.
That Final Rule included a requirement for In-Network Applicable Amounts, defined as, “Negotiated Rates, Amounts in Underlying Fee Schedules, and Derived Amounts.”
It quickly becomes a mouthful to talk about provider and payer contracted rates in the exact verbiage of the Final Rules, and “payer-specific negotiated charge” and “in-network applicable amounts” don’t really roll off the tongue.
Given the technical definitions above, the industry quickly adopted a simpler phrase: price transparency data, often abbreviated as PT data.
At Turquoise, this phrase has become a catch-all for healthcare price transparency data collected directly from CMS-mandated machine-readable files (MRFs) published by hospitals or payers that display list, cash, and/or negotiated rates.
Consolidating all the price transparency data became the highest priority as rates were confidential prior to 1/1/21, and the industry was eager to compare and analyze prices. Now, you can run searches like all the hospital prices for MRFs in a specific city or compare Ambulatory Surgery Center (ASC) rates for outpatient codes.
This data repository is unprecedented, and, as a result, several vendors sell access to price transparency data. We’ve parsed and reviewed thousands of MRFs and learned vendors are not all created equal. To help you take in what we’ve learned, we created the guide below to help anyone assess a vendor selling pricing transparency data.
Looking for someone to ask all your data questions? We’re all ears.