Healthcare is a major expenditure for employers and employees, yet Americans purchase it without insight into price or quality. Medical costs contribute to 66.5% of household bankruptcies—lack of transparency is a contributing factor. Employers, payors and providers should consider alternative models of care such as value-based plans with built-in access and transparency.
Ryan Day breaks down the current healthcare benefits landscape on the Payment Matters podcast with Jeff. Lin. Listen to learn how reference-based pricing as part of a value-driven health plan services gives employers the power to control rising employee healthcare costs.
In October 2020, CMS issued the Transparency in Coverage final rule. As part of this rule, health plans are required to publish machine-readable files (MRFs) for their negotiated rates, out-of-network allowed amounts, and prescription (Rx) coverage rates and allowed amounts. On March 1, 2022 approximately 18 months after the rule was issued, CMS locked v1.0.1 of the schema for MRFs. Getting to this “enforcement data schema” wasn’t easy. There were 20 other versions of the schema before it — and CMS may not be finished fine tuning it either.
What roles are necessary in your healthcare organization for successful application of your data analytics? Whatever the size, culture, and maturity level of your company, there are five key functions your organization needs to develop models that can help drive claims analytics solutions to address real-world problems.