Ensure near and long term compliance for Transparency in Coverage and the No Surprises Act

Activate Sapphire as your partner to ensure alignment between the near term requirements and the long term goals of the transparency regulations.

Recent transparency mandates have opened up new opportunities to engage consumers while shifting the intra-payer paradigm. But in order to embrace the benefits, plans will have to act quickly to develop defensive business strategies based on available competitor data and make build, buy, or partner decisions to comply with competing guidance and timelines.

As organizations navigate the arc of change, plans and partners will continue to weigh near and long-term opportunities and risks of upcoming mandates to set mitigation strategies appropriately. We’re here to help. 

Considering Transparency Holistically

The delivery of the transparency mandates will happen over three or more years and will require a dual focus on the underlying data and the member experience resulting from the cost calculations. Beginning with the requirement to make rates publicly available through machine readable files for in-network, out of network, bundled payments and pharmacy, the requirements shift towards making those costs visible to members in an internet based cost tool. Ask about how we are bridging these two items to minimize rework for plans. 

Understanding the Arc

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. We call this the “Arc of Transparency” and it involves these stages:

  1. Generation / Origination: Selecting the appropriate cost and business rule inputs / establishing data feeds to create the Machine-Readable Files (MRFs)
  2. Ingestion / Aggregation: Bringing in cost and business rule inputs/MRFs on a monthly basis and standardizing / monitoring for rate changes or inconsistencies
  3. Manipulation / Application: Applying business rules / plan designs and eligibility to build reliable, real-time cost estimates
  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.

Necessary Cost Engine Inputs

It has become clear that the actual data in the MRF itself is not sufficient to be able to deliver cost information within the internet-based Self-Service Tool. When it comes to generating and visualizing prospective costs for procedures to the member, additional data sets and business rules including provider, claims, groupers, adjudication rules, product rules, network rules, and benefit rules will be required. We are working with clients to ensure those details are captured along with the MRF details to ensure accurate presentation of cost in our Internet-based, self service tool.

Learn Sapphire’s Comprehensive Approach to Transparency in Coverage and the No Surprises Act

Receive a copy of our plan including our entire S365 Transparency & Care Navigation Roadmap. You’ll see how we can pave the road of transparency for you.

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