Price Transparency

CAQH CORE: Establishing the Building Blocks of Price Transparency 

The healthcare industry has seen several laws and regulations related to price transparency over the last years, including the Centers for Medicare & Medicaid Services (CMS) Hospital Price Transparency Rule, CMS Transparency in Coverage Rule, the No Surprises Act, and related regulations. The purpose of these policies is to increase consumer awareness of the cost of care and limit surprise billing practices. 

The No Surprises Act, signed into law as part of the Consolidated Appropriations Act of 2021, addresses surprise medical billing at the federal level. Section 111 of the Act requires health plans to provide an Advanced Explanation of Benefits (EOB) for scheduled services at least three days in advance to give patients transparency into which providers are expected to provide treatment, the expected cost, and the network status of the providers. Additionally, Section 112 states that healthcare providers and facilities must verify, three days in advance of a service and no later than one day after scheduling a service, what type of coverage the patient is enrolled in and provide notification of a Good Faith Estimate of charges to the payer client. 

As new price transparency laws emerge, such as the No Surprises Act, the healthcare industry is presented with opportunities to coalesce around common approaches for exchanging data in a uniform way — resulting in lower costs and greater automation across stakeholders. In 2021, CAQH CORE launched the Advanced EOB Advisory Group to develop recommendations for standardized processes to meet the Advanced EOB requirements in the No Surprises Act without creating undue burden for patients, providers, and health plans. These consensus-based recommendations were published the guidance document, Establishing the Building Blocks for Price Transparency: Industry Guidance on Provider to Payer Approaches for Good Faith Estimate Exchanges, which highlight the messaging standards, connectivity protocols, and related data content identified by the Advanced EOB Advisory Group to support the exchange of Good Faith Estimates between providers and payers.

Throughout 2022, CAQH CORE continues to engage in industry discussions, support business implementations, and educate stakeholders about the need for action and progress on these efforts through a series of focus groups and webinars centered on Good Faith Estimate and Advanced EOB requirements. CAQH CORE will use these discussions to assess additional use cases for recommendations and monitor the need and relevance to develop operating rules to support industry’s readiness to implement No Surprises Act requirements.

For more information on how to get involved with the CAQH CORE Price Transparency Initiatives, email core@caqh.org.

Audience
CAQH Program