Brad Hansen, Director of Provider Relations at ClaimDOC. Courtesy photo.

Employers expect to pay 6.5% more for health care in 2023, bringing the average spend per employee to $13,800. As employers explore cost reduction options, the government is responding with new requirements and legislation designed to increase transparency around health care pricing.

Besides the No Surprises Act, which protects people from unexpected out-of-pocket medical costs, transparency in coverage rules now require health plans to disclose pricing information for covered items and services. Having access to detailed information, however, doesn’t automatically make it usable within cost-containment strategies.

“Giving third parties, including self-funded health plans, increased visibility provides a more complete picture of health care pricing,” says Brad Hansen, Vice President of Provider Relations at ClaimDOC. “But it comes in huge submissions of data that aren’t consumer-ready. Operationalizing the data requires the ability to aggregate and analyze it.”

For self-funded health plans using a reference-based pricing (RBP) model, analyzing the comprehensive transparency data provides insights into the prices other purchasers are paying for services. The added transparency creates new opportunities to negotiate additional savings, even at a case-by-case level, while maintaining strong relationships with providers.

Turning transparency into RBP savings

Compiling and sharing the detailed pricing data required by the transparency in coverage rules has been a significant undertaking for hospitals and insurers. The latest report from the Centers for Medicare & Medicaid Services (CMS) shows that 82% of hospitals now comply with consumer-friendly shoppable services information and machine-readable data requirements. For each category, the percentage marks a sizeable increase compared to 2021 compliance levels.

The standard requirements create a vast and valuable resource that enhances the ability to compare pricing, negotiate competitive RBP rates and drive savings.

“First, third-party users of the data must have the resources and competencies to collect the data,” Hansen explains. “Then, it’s a matter of how they use it. Not all reference-based pricing approaches are the same. At ClaimDOC, we’re operationalizing the data to facilitate tough, but positive negotiations with providers that stand the test of time. The data enhances our ability to negotiate competitive rates.”

Strengthening provider relations to ensure access

Strong provider relationships also remain key to the long-term success of ClaimDOC’s approach, Hansen adds. Ideally, lower costs are achieved without sacrificing a positive patient experience, including access to providers.

“For employers, having a contract doesn’t necessarily result in provider access or a positive member experience,” he says. “The transparency efforts have created new opportunities to negotiate pricing with providers on a case-by-case basis. Along with cost savings, building strong working relationships with providers ultimately enhances the member and plan experience.”

Increased transparency gives a more complete view of the health care landscape, improving competitive pricing consistency across providers and plans. The aggregated data helps to level the playing field for self-funded plans of all sizes and provides options to analyze RBP pricing and achieve savings at the provider, case and patient levels.

Learn more about how ClaimDOC is leveraging transparency data and provider relationships to help employers optimize health care savings and employee experiences.