Payers will soon have to strip so-called “ghost rates” from their price files and have a senior executive attest that the data is accurate and complete, a requirement hospitals already face, under a final rule CMS and the Labor and Treasury departments issued Oct. 5.
The rule, which revises the transparency in coverage regulations first finalized in 2020, takes effect Dec. 5, though most of its data requirements will phase in across 2027.
Mike Vigo, chief revenue officer at UC San Diego Health, told Becker’s he believes the rule’s intent is a “positive step toward improving data quality and accountability, which can help health systems, payers, employers and patients better understand the true cost of care taking more of the factors of the equation into consideration.”
Though the rule’s mandates fall on payers and self-insured employers, Mr. Vigo said providers will carry part of the load.
“While healthcare providers will have to take on some real administrative and technology costs associated with implementing and maintaining these requirements, overall greater transparency is most valuable when it leads to more informed decisions for our patients, more productive payer-provider discussions, and a healthcare system that is easier for our community and our patients to navigate before services are delivered rather than after the bill arrives,” he said.
The rule’s changes target the size and reliability of payer data files. Payers will post one in-network rate file per provider network instead of one per plan. CMS identified ghost rates, which are rates for services a provider is unlikely to bill given its specialty, as a major driver of file bloat.
Out-of-network data should also expand. Payers will report allowed amounts once a service hits 11 claims rather than 20, with each file covering six months of claims instead of 90 days. Files will be updated quarterly rather than monthly.
The attestation must name the plan’s CEO, president or a senior executive, mirroring the hospital requirement CMS began enforcing in April. Payers must post their first revised in-network and out-of-network files April 1, 2027.
The American Hospital Association welcomed the rule, casting it as overdue parity with requirements hospitals already meet.
“Hospitals have spent years making detailed pricing information public, and we welcome efforts to bring greater transparency to health plan data,” Ashley Thompson, senior vice president of public policy analysis and development at the AHA, said in an Oct. 5 statement on the organization’s website. “This includes making personalized cost information easier to access, which is critical to helping patients make informed healthcare decisions.”
Enforcement has so far fallen more heavily on hospitals. Hospitals have been required to post their prices since Jan. 1, 2021, and payers since July 1, 2022. In that time, CMS has fined 28 hospitals for transparency violations, while no payer has been publicly fined. Regulators said in the final rule they will prioritize enforcement against plans, though pressure on hospitals has not eased: The same day the rule was released, the Federal Trade Commission sent warning letters to 24 unnamed large health systems over price transparency deficiencies.
Beyond the data files, the new payer rule requires health plans to offer personalized cost-sharing estimates by phone for plan years beginning on or after Jan. 1, 2027. Regulators declined, however, to require plans to include consumer-friendly cost summaries in their files, saying the data cannot reflect an individual’s deductible or other cost-sharing.
