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As the final deadline for the Transparency in Coverage mandate rapidly approaches on 1/1/24, many payers continue to face challenges to ensure compliance with the new regulations. These rules have important goals, but in order to truly achieve them, health plans need to be building scalable, accessible, operational tools and processes that not only achieve compliance but support more complex member experiences going forward. 

91% of health plan executives say price transparency benefits payers, providers and consumers, but 55% are concerned about meeting the mandate deadlines.

Health plans must go beyond compliance with the Transparency in Coverage mandate to provide context and guidance to members. Almost 2 out of 3 health plan executives (63%) agree that current price transparency requirements are only as effective as the user-friendly experience available for consumers. 

So, how can your team ensure that as they work toward compliance, they are also building scalable solutions for the future that deliver a better member experience? Below are three starting points: 

Establish the Cross-Functional Team for the Future.

If you aren’t already, establish a cross-functional workstream to influence your journey today, but also consider how you can use the team in the future. Gather stakeholders from across the organization and review your internal data resources to ask the difficult questions about data, systems, functionality, launch plans, and internal processes related to Transparency in Coverage. Maintain open lines of communication around active or potential issues that not only impact hitting the 1/1/24 deadline, but that could impact member experience or future growth after the 1/1/24 launch. 

Evaluate your systems.

Does your solution today scale beyond 500 shoppable services, or will the experience confuse members once more services are added? According to health plan executives, the top challenge with getting members more involved in accessing cost estimates is the complexity of the data and building for 1/1/23 is very different from building for the expanded list of services.. 

For example, many plans are using a 270/271 Electronic Data Interchange (EDI) transaction to support out-of-pocket cost estimates, but these were developed for doctor’s offices for simple queries and aren’t built to support complex benefit designs. For those plans looking at mock adjudication for generating out-of-pocket costs, consider the volume and speed required. It can take three seconds for a claim system to mock adjudicate a single claim, and if you have to provide out-of-pocket estimates for 300 providers, that’s not going to scale well. How can  your teams test, expand, or change systems as needed to ensure a seamless user experience? 

Focus on member education from the beginning.

With thousands of covered items and services, how will you help members understand all those codes and sort through them to plan for care costs? Do your rates get applied to all providers in-network so when a member searches for cardiology, it might return behavioral health specialists? How are your marketing, user experience, digital, and member-facing teams being trained on the new tools to ensure they are communicating their value and use to members at every touchpoint? There is a lot of work going into cost transparency that has the opportunity to have a significant positive impact on members – making sure they know about it and are able to seamlessly use it is critical. 

The government requirements are far from a silver bullet for helping plans, employers, and members. Simply meeting the letter of the mandate puts the burden on consumers (or health plan customer support teams) to gather information on services and billing codes, do a lot of research and analysis, and figure out what makes sense. Almost half (47%) of health plan executives surveyed recently say the hardest part of transparency is ensuring the member experience isn’t confusing.