A recent report from the Georgetown University Center for Children and Families argues that certain changes and reforms are needed to the Transparency in Coverage rule to ensure that the data are more usable and accessible by researchers.
The Transparency in Coverage Rule required insurers and plan issuers to publicly post their in-network provider rates for each covered item and service, including billed charges for out-of-network rates. While most insurers and plan issuers have followed the rule, researchers have been disappointed with the results and the report calls the published data “largely inaccessible and unusable.”
The report found that many of the data files uploaded are too large to access without using a supercomputer and that the data are too hard to understand as a layperson. There is no central repository and the data includes a “large degree of duplication and irrelevance.” The report says that trying to locate a provider in the files is “akin to trying to find a single word in a very large dictionary that isn’t in alphabetical order,” in part because “there is very little summary information or index information available.” Further, the data that is posted by plans and issuers is “of questionable quality” and there is evidence that the data doesn’t properly account for the variation in contractual arrangements between providers and payers.
However, the report notes that “many of the access and usability problems stem from the technical specifications provided by the Centers for Medicare and Medicaid Services” and that most “can be fixed through administrative action and better enforcement, with minimum cost burdens for the plans and issuers.”
Recommendations
The report made recommendations to CMS, including reducing the frequency of reporting from monthly to quarterly or even twice per year, giving users more time to analyze data and reduce compliance burdens for insurers and plan issuers. “While ultimately each plan or issuer would still need to publish the same volume of data, requiring them to post a greater number of smaller files will enable users with standard computing capacity to download and use the data,” the report said.
The report also recommended that each file be required to have clear and standardized labels and include the provider’s National Provider Identifier number; that insurers use the same file type across all users and use only a single source code for accessing information; and place a limit on the size of the file to ensure it can be opened without much difficulty.
As far as the data redundancy issues, the report recommends that CMS require a flag in the in-network file to denote providers that have 20 or more services performed in the last year, as a similar threshold is required for the out-of-network files. For data quality, the report recommends that CMS review a random sample of files to determine data quality during each posting period and issuers with poor data quality should be made to take corrective action. Additionally, creating a public-facing portal and reporting template for users to submit potential violations of the posting requirements and potential data quality problems would help to boost the usability of the system as well.
Upcoming TiC Expansions
On January 1, 2023, the Transparency in Coverage requirement expanded to require plans and issuers to make cost-sharing information available for 500 items and services identified and starting January 1, 2024, plans and issuers must make cost-sharing information available for all items and services for plan/policy years thereafter