Misconceptions of Price Transparency Data
Claims Data Is The Same Thing As Price Transparency Data
Claims data is not the same price transparency data. This is one of the biggest misconceptions about price transparency data. This data is pulled from historical patient visits codified in 835 and 837 files. These files are used to exchange information from providers and payers electronically. Because this data contains patient health information (PHI), it is de-identified and typically shown in aggregate for reporting or general trends.
Price transparency data comes directly from MRFs required by the Hospital Final Rule and TiC. It’s a granular look at exact gross charges, list price, and negotiated rate for all items and services. It’s updated as often as once a month, so it’s more current than claims data.
Even If A Hospital Hasn’t Posted Their Rates, A Payer Might Have (And Vice Versa)
Although we’ve seen a steady upward trend of compliance and completeness of hospital MRFs, there may be the occasional rate you expected to find in a hospital file but could not. Payer MRFs must contain all hospital-negotiated rates. So while you may not find the cash price, the negotiated rate should be available in payer data. If you’re unfamiliar with rate types, the cash price is as it sounds, the amount a patient would pay in cash. The negotiated rate is the agreed upon rate that a payer will pay a hospital for a particular item or service. It’s the rate they “negotiated” over and then mutually agreed to.
Conversely, what if you have trouble finding a rate in a payer MRF? If it’s a hospital rate you’re looking for, you can check the hospital’s MRF data. Or, maybe it’s a non-hospital entity, the payer file is the way to find it. When shopping for healthcare for yourself or a family member, check the payer’s Patient Estimate Tool. This houses a minimum of 500 common items and services.
When all else fails, payers must update their files monthly, meaning the rate could appear in the next month’s MRF if it’s missing from the current one.