top of page
  • Writer's pictureJoseph Tollison

Peeling Back the Layers of Health Plan Price Transparency: A Journey Towards Democratized Data

Today, I’m sharing my thoughts on price transparency in healthcare, a topic that holds promise for making healthcare more affordable. The idea of making things open and clear to spread power and increase wealth isn’t new. It's seen in how personal computers came about, and in the foundation of capitalist and democratic societies.

I speak for our team at Payerset, who work with price transparency data daily, and from what we see, it’s going to be a long ride. But, there’s hope, as we’re already seeing some positive changes on the horizon.

When you first hear about price transparency data, it might sound like a way to peek into the secret deals on rates between payers and healthcare providers. And yes, the rates for the same services often vary a lot. But as we dig into this data, we find there’s much more to be uncovered, things we didn’t think of at the start of this journey to open up this information.

One big eye-opener is the messiness and complexity of the contracts themselves.

One big eye-opener is the messiness and complexity of the contracts themselves. Our dive into the data shows that through messy deals or company mergers, there's no simple relationship between an organization (like Baylor Scott and White) and their rates for services. Usually, it’s more like a puzzle. One organization, under one tax ID, with many provider IDs tied to that tax ID, and then multiple contracts tied to various provider IDs (contracts and rates might even be tied to small or unexpected facilities). And then, you need to piece it together because different billing codes are tied to different provider IDs. The mix of different negotiated rate types tied to facilities where you wouldn't expect them adds to the complexity.

On top of this, we still see issues with payers meeting the rules. Just last week, we found a big payer missing major provider IDs in their data, flagged what was wrong, and opened a ticket with CMS. The customers we work with, who have been part of contract negotiations for years, confirm that this messy picture actually reflects the real situation out there.

This messy picture actually reflects the real situation out there.

On the outpatient clinic side, it’s interesting to see rates tied to individual providers. In one case, a single tax ID had 436 providers tied to it. What our customers might find is that this data is just duplicated over and over. We see many examples of “rate stuffing” where a payer will just copy the same rates under the provider IDs for the same tax ID. This is a way for the payer to follow the law, while making the data so big that it becomes almost impossible to work through and analyze (unless you are Payerset, of course).

Seeing the complexity of these contracts in the industry has been a big part of understanding price transparency. Some organizations have everything under one contract while others have many contracts tied to different provider IDs.

All this confusion is going to come into the light. What's important now is getting this information to people who understand contracts well, actuaries who understand rates well, and organizations like accounting firms and other healthcare consultants who want to use this information to help their clients.

Like I said, it’s going to be a long journey, but we’re already seeing early movers and healthcare experts holding payers accountable for these messy and inaccurate contracts, and the big variations in service rates. Change is on the way!

It’s going to take a lot of hard work. But Payerset will open up this information and get it into as many hands as possible so that they can do good with it. Thank you all for your partnership and dedication to making healthcare better. Thank you for teaming up with us on this journey.

Payerset is price transparency, simplified.



Commenting has been turned off.
bottom of page