Healthcare Cost Transparency May Soon Be a Regulatory Requirement. What’s Your Plan?

Healthcare Cost Transparency

It’s no big revelation that the cost of healthcare, or more specifically, the fear of surprise bills, is a major source of tension for both your members and your organization. Many forward-thinking payers have already responded by offering healthcare cost transparency tools and materials. Transparency helps increase trust in healthcare and can improve member satisfaction and quality of care.

But the time of cost transparency being something that’s nice to have may soon be over. Instead, this may become a must-have. Because it’s no longer members, payers, providers, and pharmacists talking about the cost of healthcare…now politicians are taking action.

Healthcare is one of the most heated and divisive subjects on the national stage, pushing Washington to seek solutions that it believes will reduce healthcare spending and meet the demands of their constituents. Among those solutions are proposed regulations that will require payers to provide members with instant estimates of their out-pocket-costs.

So let’s dig into this…

The latest effort to improve healthcare cost transparency involves a number of rules from the Departments of Health & Human Services, Labor and Treasury.

  • CMS-1717-2 would require hospitals to post in a searchable format the payer-negotiated prices for 300 shoppable services.
  • CMS-9915-P, the Transparency in Coverage proposed rule announced last November, would require insurers to post online real-time cost-sharing information as soon as 2021. Posted cost ranges would have to include in-network provider negotiated rates and historical out-of-network allowed amounts.

Various industry groups including the AHA have filed suit, saying that the proposed regulation exceeds the federal government’s authority, will be administratively difficult and expensive to implement, and could decrease competitive advantages by making negotiated prices (considered proprietary trade secrets) public.

CMS is also proposing to expand a plan finalized last year that requires Medicare Advantage Part D plan sponsors to lower beneficiary cost-sharing on some of the most-expensive prescriptions and make real-time prescription prices available across all medications. The expansion would require MA plans to post real-time prices for Part D prescriptions and enable their members to compare out-of-pocket payments and consider alternatives, beginning in 2022.

Where do we go from here?

Whether or not these proposals become law, does little right now to get down to the individual member level and doesn’t mandate a single view that pulls together costs coupled with quality ratings. Between ongoing information system interoperability challenges, security concerns and a lack of mandates to present quality ratings alongside these costs, the effort will still have limited value. And what the government is proposing represents an enormous amount of cost data to gather, maintain, and post for each of the thousands of insurance plans.

In the face of these changes, Healthx believes that it is better to be prepared. Payers can either get ahead of these regulations, and begin sharing pricing data with their members now, or they can be left scrambling, if and when these laws go into effect. And regulations notwithstanding, we just think it’s good consumer practice to provide your members with information, including the cost, that empowers them to play a role in their overall care.


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