Insurer price transparency has arrived: The law mandating that health insurers must publicly post prices they have negotiated for almost all procedures and items with hospitals, doctors and other suppliers went into effect July 1, 2022.
The Centers for Medicare and Medicaid Services wrote on the web that the move was “empowering consumers with the necessary information to make informed health care decisions.” The insurers are to post negotiated service rates and out-of-network allowed amounts between health plans and healthcare providers.
In truth, the machine-readable files released on Friday are not consumer-friendly. But a Jan. 1, 2023, introduction of consumer-friendly tools should be another step in the right direction. This is an optimistic view, of course; insurers and hospitals have tried to make price estimator tools before, and their performance has been mixed — also, there’s no accountability if the estimate is wrong.
Transparency regulations can be a mixed bag. While hospitals had a spotty response to the transparency regulations mandating that they post their prices, insurers appeared to be complying, according to our spot check.
Employers are also supposed to post prices. I saw a number of them doing so, but it’s hard to say that all are doing it, or doing it well. It seems that the insurers are posting prices on behalf of the companies that they insure.
But after sifting through the various sites and downloading one file, it seems obvious that these are not files that can be easily used by a consumer trying to figure out what she’ll pay for a simple MRI. They are hard to find, and they have gigabytes of data. You would need to be an expert in big data with a lot of processing capacity to derive benefit from the ones I saw.
The expectation is that this information will be used inside of the industry — one company, Turquoise Health, has been described as a potential user. Turquoise has collected a number of hospital price lists, and makes them available on their site — and also uses the data to sell services like compliance, payment checking, rate setting and so on to providers, payers and employers. So this data is likely to be used by the big players who can mash it themselves or pay someone to mash it for them — presumably so they can make more money.
Insurer files posted online
UnitedHealthCare posted its machine-readable files here. “These files provide pricing data for covered items and services based on in-network negotiated payment rates and historical out-of-network allowed amounts. A third machine-readable file for prescription* drug rates and historical costs has been delayed pending further guidance,” UHC wrote. The cost estimator tool mandated in the law is due on Jan. 1, 2023.
I went to download the page but it said it would take as long as 5 minutes. I left and then came back and did it, and it was a catalog of links to employers’ plans. Good Samaritan Hospital, Good Times Restaurants…There were 22 references to “Times” and 185 references to “York.” I saw Palm Beach County School district and countless others.
There are 77,251 files for various employers as of July 3, ending with “totes-isotoner.”
Cigna’s machine-readable files are here. Cigna wrote: “Important note: 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, which has significant system requirements for use. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download.”
Humana’s files are here.
Anthem’s machine-readable files are here. Anthem wrote: “A machine-readable file is defined as a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention, while ensuring no semantic meaning is lost. These files are in the CMS defined format (JSON) and are not meant for a member-friendly search of rates, benefits, or cost sharing. Members should log in to www.anthem.com for this information.
“The table of contents is an approved CMS schema approach that combines the in-network rate files and references the locations (URLs) from which the appropriate files can be downloaded. To view a list of all machine readable files and associated urls published, click the Table of Contents link below and follow the prompts.”
When I tried to download the Table of Contents, my laptop said it would take an hour, so I canceled.
Anthem noted that the files could be searched for an individual employer’s results, using the Employer Identification Number.
Medical Mutual has its files here.
Kaiser Permanente files are here.
Employer files online
The New York Times referred people to the United Healthcare site, as you can see here.
“To comply with the rule, customers of insurors must post a link on a public website that directs consumers to the cost information, which must be available in machine-readable files,” The Times wrote. “UnitedHealthcare creates and publishes the machine-readable files on behalf of The New York Times. To access the files, please visit the UnitedHealthcare transparency website. The UHC site was the same one that promised to take five minutes to load.
There seemed to be about 10 downloadable files related to The New York Times, including an EPO, Harvard Pilgrim Choice Plus POS, POS Choice Plus allowed amounts, and so on.
I finally downloaded one New York Times file, in JSON, but it seemed to be empty. (I am not a JSON expert.)
Cle-Care with Medical Mutual of Ohio was downloadable via the MedMutual.com website. I found our old friend 72148 CPT code, MRI of the lower back without dye, with a negotiated rate of $78.62, which is quite low, but it’s not clear if or how a civilian would use this information. That file had more than 43,000 lines.
UHS of Delaware posted links to machine-readable files for Blue Cross, Aetna and UnitedHealthCare for the UHS Welfare Benefits Plan here.
The American Red Cross posted links to the Red Cross machine-readable files for 16 insurers here.
Shenandoah University directed people to anthem.com for this information.
UCLA Health is here, but the links to the Ronald Reagan and Santa Monica Medical Center and the Resnick Neuropsychiatric Hospital both crashed my browser.
The National Council of Examiners for Engineering and Surveying referred members to the Cigna page.
The regulation for insurer price transparency
These are the three steps for health plans and issuers, CMS wrote:
“1. Machine-Readable Files containing the following sets of costs for items and services
In-Network Rate File: rates for all covered items and services between the plan or issuer and in-network providers.
Allowed Amount File: allowed amounts for, and billed charges from, out-of-network providers.
hospital price transparency number two icon
“2. Internet-based price comparison tool (or disclosure on paper, upon request) allowing an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers, for 500 items and services.
“3. Internet-based price comparison tool (or disclosure on paper, upon request) allowing an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers, for all items and services.”
In the next step, CMS wrote, “By plan or policy years beginning on or after January 1, 2023, most group health plans and issuers of group or individual health insurance coverage are required to disclose personalized pricing information for all covered items and service to their participants, beneficiaries, and enrollees through an online consumer tool, or in paper form, upon request. Cost estimates must be provided in real-time based on cost-sharing information that is accurate at the time of the request.”
“Beginning July 1, 2022, CMS will enforce applicable price transparency requirements. For plans and issuers that are subject to CMS’s enforcement authority and do not comply, we may take several enforcement actions, including: requiring corrective actions and/or imposing a civil money penalty up to $100 per day, adjusted annually under 45 CFR part 102, for each violation and for each individual affected by the violation.”