With the ongoing implementation of regulations aimed at increasing price transparency, like the machine-readable files (MRFs) mandate, the healthcare industry is undergoing a significant transformation.
Dennis Charland, Zelis SVP Sales, Transparency and Data as a Service, recently sat down to provide valuable insights on the implications of MRFs and their impact on the market. Listen here:
Understanding the challenges
While it’s true that payer MRFs have a lot of great information, it can often feel like both too much and too little. Let us explain.
MRFs contain data encompassing a payer’s entire contracted rate set for in-network providers. The issue? The data within MRFs are not readily usable for consumers due to sheer size and complexity. Because, let’s face it, most of us lack the computing power and understanding (as well as time!) required to effectively interpret said data.
And despite the vast data available, you can’t get a full picture with an MRF alone. In order to fully use the information in MRFs, you must complement it with other provider demographic information, such as names, specialties, addresses, and affiliations.
That’s just the beginning of the challenges.
On top of that, there are currently four types of files being published.
- Tables of contents (TOC) – While not required in the regulation, most carriers produce at least one, but more than likely, many, of these. They are dozens to tens of thousands of lines long, list medical plan IDs, and point to other files where the “lower-level” details of reimbursement rates can be found.
- In-network negotiated rates – These are single documents that provide rate data on specific medical codes and pricing for in-network medical providers and can be anywhere from a few kilobytes to many terabytes in size. But that’s not all. Several in-network files, up to hundreds, may need to be combined to completely understand one plan, and many plans may point to the same in-network files.
- Out-of-network allowed amounts – Similar to in-network files, these files provide rate data but focus more on observed payments to out-of-network providers. Good news: These files are more manageable. Bad news: There is very little meaningful information to gleam.
- Provider reference – Provider references contain lists of medical provider IDs. And while this data can exist directly in in-network files, carriers have the flexibility to alternatively point at separate provider reference files containing similar content.
The data are interconnected across file types, but to assemble a full picture you must link these file types together. And that means the files are large. For the top four payers, Zelis is downloading and storing ~2TB of MRF data each month.Which is equal to 1,456,354 floppy disks, 2,600 physical filing cabinets of paper, or 13 million document pages, commonly stored as Office files or PDFs.
And due to the massive amount of data involved (and mentioned above), simply complying with the regulation can be challenging for payers.
Why? This data must be updated monthly and made publicly accessible without restrictions, including limitations on downloads and password protection. The data must also be made usable for member-facing transparency tools, which require fast and efficient access to up-to-date contracted rates.
But it’s not all rain clouds and no reward.
Unlocking market opportunities
Despite the limitations, the release of rates data presents unprecedented opportunities for payers, providers, and third-party developers.
Previously, organizations relied on market basket data, clearinghouse service data, coordination of benefits (COB) data, and assumptions to understand competitors’ pricing. With MRFs, this information becomes publicly available in a more usable and actionable format, revolutionizing how businesses evaluate pricing strategies, drive reimbursement rates, and gain a competitive edge.
Third-party tools will play a crucial role in providing solutions as MRF guidelines evolve.
While it’s true your organization can access these files, it is incredibly difficult to turn these -available data into actionable insights. You must acquire, clean, and complement the data to make it ready for in-depth analytics.
To stay ahead of the competition and maintaining a contracting edge , you will need a partner that offers comprehensive solutions in this domain, supporting you with data acquisition, cleaning, and customizable analytics tools for efficient and accurate rate analysis.
The wrap up
As regulations continue to evolve, it is expected that refinements will be made to the MRF datasets. We are anticipating, gaps in the current data, such as percentage of charge contracts and risk-based deals, will be addressed to provide a more holistic view of healthcare costs.
As such, it is crucial to select a partner capable of adapting and evolving alongside regulatory changes to ensure the continued success of your organization and overarching transparency initiatives.
To see how Zelis can help you leverage MRFs, connect with us.
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