On July 1, 2022, the Federal Price Transparency Rule (the Rule) went into effect for commercial health plans. Under these requirements, certain health insurers must disclose their in-network negotiated rates as well as their out-of-network allowed rates. The insurers are required to publicly provide this data on their websites as machine-readable files (MRFs) that follow a CMS-provided schema. The purpose of the Rule is to help outside organizations to understand these negotiated prices with providers in an effort to eventually help consumers price-shop for their healthcare services.
While most payers comply with the Rule to some degree, the MRFs are monstrous in both size and complexity. Only a few organizations have been able to parse the data. Each file produces gigabytes and gigabytes of data – the vast majority of it not applicable to any meaningful analysis. Moreover, each payer also complies with the requirements differently, for example by using different billing code modifiers in their disclosed rates, which leads to difficulties in comparing prices “apples to apples.” The net result of the size and complexity of the MRFs is that garnering insights from this very important data is difficult for most organizations and impossible for consumers. However, combining MRF data with data in CareJourney’s offering allows us to understand price variations between plans, providers, and markets.