Quality of Price Transparency Data

Price transparency data, especially the payer-posted rates under the Transparency in Coverage Rule, has been criticized for being unreliable.

Concerns over its usability, completeness, and accuracy are widely discussed in the healthcare sector, with significant room for improvement through regulatory action.

• Usability: The current file format is cumbersome and inconsistent for the volume of data being conveyed. And, while the content is specified, the way in which the content is organized isn’t, which leads to significant variability that forces any user to decode the layout of the files by payer and then renormalize it to some standard before ingesting. National carriers, for example, may post tens of thousands of in-network files, making it hard to locate specific network products. To improve, payers should be required to provide detailed guides explaining how files are organized by market, product, plan, and network arrangement.
• Completeness: It’s unclear how comprehensive the data is. While the machine-readable files (MRFs) are supposed to include negotiated rates for all services across providers, some files lack key information (e.g., institutional rates or rates for certain codes). To improve completeness, summary statistics should be included, showing the percentage of contracted providers and services along with details about varying contract terms. These statistics should be validated by the reporting entities’ chief compliance officer.
• Accuracy: Rates listed in MRFs must reflect the “true” contracted rates, but analyses often reveal discrepancies between the listed rates and what’s known about providers. Machine-readable files should be validated quarterly against a representative sample of claims data paid by the payer for each network arrangement, matching rates and provider details to ensure accuracy. Validation results should be posted quarterly and attested to by the reporting entities’ chief compliance officer.

On Feb. 25, President Donald Trump signed an executive order to tighten enforcement of healthcare price transparency mandates, focusing on:

• Actual Prices: Ensuring the disclosure of actual prices, not estimates.
• Standardization: Updating guidelines to ensure pricing information is easily comparable.
• Enforcement: Establishing a framework to ensure compliance with accurate and complete reporting.

The executive order gave several executive branch departments 90 days to require actual-price disclosures and to issue guidance concerning these compliance and data quality improvement goals.

In the meantime, it’s crucial to ask vendors five questions about the quality of their price transparency data:

1. Does your price transparency data product team include healthcare actuaries and reimbursement experts?

2. What primary rules govern your MRF data processing logic?

3. What methods do you use to ensure the appropriateness and accuracy of MRF rates?

4. Do you perform gap-filling in your data processing? If so, what is your methodology?

5. Do you offer data quality scores to understand confidence levels in the data?