Price transparency is here.

Price transparency in healthcare involves publicly posting the negotiated reimbursement rates between healthcare providers and insurance carriers. This is done by hospitals and payers, respectively. Historically, these rates were confidential. However, the Federal Hospital Price Transparency (2021) and Transparency in Coverage (2022) laws now require that these negotiated rates be made openly available online.

Payer price transparency data refers to the information that health insurance companies (payers) are required to disclose about the prices they have negotiated with healthcare providers for various medical services. This data includes detailed records of rates for medical procedures, services, and items, as negotiated between payers and providers. It is mandated by regulations such as the Hospital Price Transparency Rule and the Transparency in Coverage Rule.

The purpose of this transparency is to empower patients, employers, and other stakeholders to compare prices across providers and payers, enabling more informed decision-making and fostering competition in healthcare.

Payerset leverages this data to provide comprehensive datasets and self-service data exploration, allowing organizations to use the information for cost management, competitive pricing, and strategic planning.

See the CMS Transparency in Coverage Overview here.

The TiC final rule, issued in 2020 by HHS, DOL and Treasury (CMS-9915-F), requires most commercial health plans to lift the veil on pricing. Insurers and self-funded employer plans must:

1. Post three machine-readable files online— in-network negotiated rates, historical out-of-network allowed amounts, and prescription-drug pricing (the latter delayed pending further rule-making). Sources: CMS.gov and KFF.org
   

2. Phase in a consumer cost-comparison tool giving members real-time, plan-specific out-of-pocket estimates for 500 shoppable items which began on Jan 1, 2023 and all covered services as of Jan. 1, 2024. Source: CMS.gov
   

3. Publish the machine-readable files which began on July 1, 2022 and refresh them monthly so anyone—researchers, competitors, employers—can analyze the data. Source: CMS.gov

Payerset retains all detail posted by the insurance companies within their machine readable files (MRFs) and further enriches and cleanses that data for analytics and insights.

Here is an overview of what Payerset data includes and its level of detail:

Nationwide Negotiated Rates

The data includes negotiated rates for medical procedures, services, and items between payers (insurance companies) and healthcare providers. These rates are the actual amounts that insurers agree to pay providers.

The rates are broken down by service, provider, and location, allowing for granular analysis of healthcare costs across different regions and providers.

Billing Codes and Descriptions

Detailed billing codes (such as CPT, HCPCS, & DRG) and descriptions for various medical services and procedures.

Includes comprehensive coding information which is essential for understanding specific healthcare services and their associated costs. Plans and Providers

We provide all commercial plans and networks for a full picture of the payer's reimbursement rates by NPI (National Provider Identifier)

Covers all providers and plans, offering a complete view of the U.S. healthcare market.

For more details, please see our Data Dictionary here: https://docs.payerset.com/rate-explorer/data-dictionary

Payerset refreshes its data quarterly. This means that every three months, Payerset updates and audits its entire data set to incorporate the latest changes in payer data structures, negotiated rates, and any new regulatory requirements. These regular updates ensure that users have access to the most current and accurate information available.

Payerset always keeps this full historical payer data accessible.

Please see our latest payer compliance audit results here: https://docs.payerset.com/payers/aetna-price-transparency

While both payer & hospital price transparency, respectively, aim to promote transparency in healthcare costs, hospital price transparency focuses on the charges for services directly from hospitals, and health plan (payer) price transparency focuses on the rates negotiated between insurers and all care delivery organizations (including hospitals) and individuals.​​

If you’re on our website, the answer is likely ‘yes.’ Here are a few common uses amongst different price transparency users:

• Hospitals and health-system finance teams to benchmark competitors’ rates and strengthen payer negotiations.

• Health insurers and TPAs to monitor network adequacy, pricing parity and compliance.

• Employers and benefits coalitions to audit what plans pay on their behalf and choose high-value providers.

• Health-tech, analytics and revenue-cycle vendors to power pricing calculators, member-facing apps and reimbursement products.

• Researchers and policymakers to study price variation and inform payment reform.

We learn of new ones almost daily. But here’s what we see most often.

• Rate benchmarking and contract negotiation: Compare your prices to market medians to target over- or under-performing contracts.

• Network strategy and market entry: Identify high-value providers, spot gaps and modeling scenarios.

• Revenue-cycle, chargemaster and pricing audits: Detect underpayments or overpriced services and optimize reimbursement.

• Academic and policy research: Quantify price variation, study competition and inform payment-reform proposals.