Federal agencies ramp up pressure to improve health insurer performance
Whether it’s bringing uniformity to data files or congressional panel oversight, there’s more focus on consumerism, visibility and affordability.
The federal government continues to push its levers to enable easier exchange of information between payers, providers and consumers.
Most recently, the Centers for Medicare & Medicaid Services, in collaboration with the departments of Labor and Treasury, released a new proposed rule to enable transparency in coverage.
All this comes as congressional pressure grows to put limits on bad insurer behavior – the focus of a congressional hearing on January 22.
These divergent efforts are aimed at making data transmission more seamless and transparent, while keeping consumers protected and better informed about their own care.
Transparency in coverage
Improving transparency in healthcare pricing has long been on the radar screen for the federal government. The No Surprises Act was signed in December 2020 with a goal of protecting people with health insurance from surprise medical bills, primarily banning balance billing for most emergency services and other care actions.
The Act has been updated and revised over the years to achieve its goals as problems arise and technology evolves. For example, in 2022, the federal agencies released a final rule updating several provisions of the act that included guidance on how to conduct independent reviews of disputes over charges. Also, in 2021, it began efforts to explore the use of a standards-based API, using the Fast Healthcare Interoperability Resources (FHIR) standard, to aid in the development of an Advanced Explanation of Benefits (AEOB).
Last month, in the latest proposed rule, the agencies are looking to take steps to eliminate barriers that have impeded access to pricing disclosures “to participants, beneficiaries and enrollees,” aiming for further standardization in the way data is exchanged.
Specifically, the rule seeks improved standardization, accuracy and accessibility of the in-network rate and out-of-network allowed amount. It identifies the culprit as irregularities involving the machine-readable files that are exchanged. Updates also are needed for Internet-based self-service tools that consumers can use, according to analysis from Turquoise Health, a software company that provides a price transparency platform.
Fixing issues
The proposed rule seeks to fix three key issues with the original price transparency rules, says Carol Skenes, the company’s chief of staff.
To overcome these barriers, the departments are proposing changes to improve the usability of MRFs, according to an article by Skenes for Turquoise Health. First, these files must not contain items or services “that are unlikely to be furnished by a given provider,” such as a service that’s not in a specialist’s typical range of services.
The new rule also focuses efforts on minimizing duplicative data “by proposing payers report rates at the network level,” mimicking the way hospitals report rates in their own MRFs, so as to better harmonize requirements between providers and payers.
Finally, the proposal targets several different aspects of data utility to ensure data is easy to locate. It’s targeting claims thresholds and lookback periods; additional data elements; and a change-log MRF to reflect changes in the in-network file over time.
Among other provisions, the rule seeks to enable data to be better utilized by patients using Internet-based self-service tools to receive more accurate and useful patient estimates of charges.
While the rules, if finalized, won’t go into effect until early next year, providers and payers need to anticipate the changes, Skenes says.
"Both hospitals and payers will be updating their machine-readable files (MRF) in 2026 in preparation for new requirements,” she says. “Challenges may arise as MRF generation teams must adjust their existing processes to maintain compliance and adhere to the new policies. The updated requirements do build on the existing MRF infrastructure though, which should minimize some potential stress placed on information systems."
Shining a spotlight on bad practices
Insurers are continuing to receive attention for bad behavior related to health coverage. Those practices were highlighted in a hearing before the House Committee on Energy and Commerce and the House Committee on Ways & Means.
Among the organizations presenting at the hearing was the American College of Emergency Physicians (ACEP), which cited a range of “abusive and unscrupulous tactics, including explicit violations of the No Surprises Act, abuses of prior authorization procedures, repeated attempts to undermine and erode the federal prudent layperson standard, and outright denials of care.”
The hearing, with five CEOs of the nation’s largest health insurers, focused on the unaffordability of healthcare for Americans.
“Ideally, insurers would help control costs and guide patients through our complex healthcare landscape,” said Rep. Jason Smith (R-Mo.) in an opening statement. “But today, patients are forced to navigate systems designed around insurer priorities, not patient needs.”
But while Smith and Republican colleagues simplistically and universally blamed Democrats and insurance companies for soaring healthcare costs, insurance executives tried to explain the complex dynamics driving healthcare costs higher.
For example, Paul Markovich, president and CEO of Ascendiun, the parent company of the nonprofit Blue Shield of California, told the congressional panel that healthcare's systemic failures are driving high costs and leaving many Americans without affordable coverage.
Markovich pointed to long-standing structural problems and misaligned incentives across the healthcare ecosystem. "We are a long way from that ambition right now because there's too many times where participants in the current healthcare system — health plans, hospitals, physicians, pharmaceutical companies and others — put profits ahead of patients and are complacent about how complex, inconvenient and inefficient our system is."
Markovich noted that the consequences of inaction fall on American families, employers and taxpayers, who are increasingly strained by inconsistent, impersonal and inefficient care. “The good news is that we can fix this if we have the collective courage and conviction to do so. It starts by recognizing that we must fundamentally change this flawed system, and we must all take accountability for doing so," he said.
Fred Bazzoli is the Editor in Chief of Health Data Management.