By Gretchen Hayden

Gretchen Hayden is a writer creating insightful content across the healthcare revenue cycle. She produces content for Zelis and previously for Sapphire Digital, a leading member navigation and shopping platform. With a deep interest in healthcare finance, Gretchen helps Zelis clients stay current on trends in the healthcare payments market, with an engaging and provocative perspective.

The technical guidance isn’t fully available and details are slow to emerge but the compliance dates remain the same. In an effort to bring transparency to the transparency challenge, here is how Sapphire is helping clients through these regulations.

While we will continue to update as new information emerges about dates and expectations, we wanted to provide a bit more detail on what we are doing to support these regulations for our clients.

The Arc of the Regulations

As an overarching narrative, the combination of regulations we have seen in the past few years will significantly change the consumer interaction model for healthcare. Accurate cost visibility and health data ownership will more tightly align healthcare organizations to the consumerism models the American consumer has become accustomed to in all other parts of their lives.

While there is an immediate focus on hitting the initial dates of theTransparency in CoverageandConsolidated Appropriations Act(which includes the No Surprises Act) requirements, it is critical for us and our clients to think strategically about how these new laws will impact the future of healthcare so we can partner for the most strategic and valuable delivery of these requirements.

We have begun to discuss this as an arc of change to an evolution of healthcare. These are the key stages:

  1. Stage 1: Generation / Origination:Selecting the appropriate cost and business rule inputs / establishing data feeds to create the Machine-Readable Files (MRFs)
  2. Stage 2: Ingestion / Aggregation:Bringing in cost and business rule inputs/MRFs on a monthly basis and standardizing / monitoring for rate changes or inconsistencies
  3. Stage 3: Manipulation / Application:Applying business rules / plan designs and eligibility to build reliable, real-time cost estimates
  4. Stage 4: Presentation / Contextualization:Bringing cost estimates to UI layer and giving consumers the appropriate level of context to make informed care decisions
  5. And Beyond:Solutions that emerge from this new cost centered approach to healthcare.

Stage 1: Generation / Origination

Machine Readable File (MRF) Availability

Since the regulations emerged, we have been in continuous dialogs with our clients about the requirements to produce the Machine Readable Files within this regulation. We are also continually monitoring theCMS Github Page, where technical guidance is being published. These conversations typically involve selecting the appropriate cost inputs and establishing data feeds to create the Machine Readable Files required by 1/1/2022. Depending on the size and complexity of the client organization, some have the teams and data to deliver the files in house and some require assistance from a partner to deliver on what’s required.

For those clients who need our assistance, we are preparing a Machine Readable File solution that is both compliant and ready. This process involving data identification, aggregation, normalization, and presentation into a publicly available location is underway with many organizations right now. As part of that, we are helping bring supporting IT services to help clients source and verify the data needed to supply the file generation.

For clients who are managing the MRF requirement within their organization, we are actively partnering to establish, align, and deliver solutions rooted in the same standards and file ingestion protocols. By doing so, we and our health plan partners believe we will increase the value of the shared files by making them usable in a number of file interchange circumstances as those needs arise. Together, we are focused on delivering standard file formats and standard publishing rules to build confidence in the cost information delivery system tied to these regulations.

Stage 2: Data Ingestion / Aggregation

The existence and availability of the Machine Readable File is only part of the solution. To be able to generate accurate and useful cost information for members in the proposed cost estimation circumstance, plans will likely need to move data back and forth. In order to do that effectively, the plans will need a central place to collect and distribute this information between plans.

Our cost data hosting and management solution provides a consistent, known, reliable location to host and transfer these files as well as a layer of additional value-added services to find and eliminate missing data, missing linkages or other essential information.

Stage 3: Manipulation / Application

Generating accurate costs and presenting them to members is something Sapphire has been doing for over a decade. Our leading digital healthcare shopping and transparency platform along with our concierge support model helps tens of millions of members find and access the right care at the right moment and, with incentives, at the right price.

Built on a strong foundation and pressure tested for years, our cost engine is an essential and central component of our platform that makes this seamless care navigation possible. Building on the shared experience we have with our clients, we know that the information stored within the MRF may not be enough to effectively present the cost to a member. At the very least, a layer of business rules and correlated reference data sets will need to augment the MRF data set in order to present the right information to the member at the right time.

And further, the results from our cost engine will need to consider the cost requested at the stage in the member journey and potentially tie in member guidance for how best to make use of the cost information at various stages of the care journey.

Over the next 6 months, our best-in-class cost engine is being extended to address the internet-based cost requirements of the next stage in the regulation. Focused first on the first 500 procedures in line with the 1/1/2023 Transparency in Coverage requirement (see No Surprises Act discussion below), our engine considers the inputs above along with the user experience needs of the Internet-based self-service tool to bring the right cost at the right time with the right context. In a continuous improvement model, we will then extend to address the balance of items needed to achieve the all procedure costs requirement—all with an eye towards cost comparison to allow the end user to make value-based care choices with the best tools available.

In parallel and in service to the No Surprises Act ruling, we are considering the potential needs of the CAA technical guidance due out in July of 2021 as it relates to cost transparency, provider directory requirements and the Advanced EOB requirement.

Stage 4: Presentation / Contextualization

Our intuitive provider discovery and cost transparency tools make it easy for members and patients to select better, more affordable care—helping them feel more in control of their health care spending.

Our configurable, searchable provider directory presents physicians and facilities to members in both authenticated and unauthenticated member experiences. We process over 2.75 billion transactions per year in a complex array of data relationships and serve over 41 million unique users per year. In partnership with our clients and partner associations, we regularly validate and update the details of the data in our directory files and taxonomies to ensure members can always find a provider or facility to meet their needs.

Our robust cost engine combines multiple data sources with individual-level data to provide accurate out-of-pocket estimates that are presented to members in easy-to-read, easy-to-understand cost breakdowns and cost comparisons. Along with a number of other capabilities to support members in efficiently finding and understanding care cost and quality, our platform is ready and able to scale in support of the new cost presentation requirements.

With the requirement to deliver cost estimation for 500 shoppable procedures within a self-service internet-based tool by 1/1/2023, we have already begun to account for the cost variations. Working in partnership with our clients, their end users, and our world-class cost team, we are working through the variations for the hundreds of permutations we anticipate customers expecting based on factors including plan design, time of year, clinical need, care path, and status of accumulations.

In parallel and in service to the No Surprises Act ruling, we are immediately mapping the cost comparison requirements to our exciting capabilities in anticipation of the technical guidance due out in July of 2021.

Delivering next stage value with the data

Beyond compliance with the regulations, the healthcare consumer experience will change as a result of this focus on cost visibility and cost accuracy. This will likely give rise to new tools and services for end users, plans and providers to navigate in this new cost-driven environment. We will continue to advise and support our clients with new capabilities as these needs and opportunities arise.