Turquoise's public comment on CMS-1834-P

It’s been a summer of public comments so it only feels right to have one more comment out in the world just before fall. Grab your pumpkin spice latte and read on to hear the highlights of our thoughts or click here to read the full public comment.

TL;DR: Enforcement of Advanced Explanation of Benefits (AEOBs) alongside thoughtful MRF standards are the changes we need to make

The world of price transparency has spent the last four years steadily adding each negotiated rate into massive publicly available files that insurers and hospitals are required to post. You’ll find that a majority of our comments are deep into the specifics of percentile allowed amounts, taxonomy codes, EDI 835 ERA transaction data, and stop-loss. Those of you who know what all that means will love our full comments.

For those unwilling to get stuck in acronym soup, the machine-readable files (MRFs) are unusable to a regular patient, nor should we expect patients to open Excel to figure out their healthcare bills. Industry leaders, hospitals, payers, and elected officials all ask us the same thing: when does this data enable a patient to shop for care in advance? The intention was to create patient estimate tools (PETs) to allow patients to better understand prices. However, these requirements push health plans and hospitals to post rates by individual code, rather than easily understood bundles. After all, the average patient isn’t going to know to combine colonoscopy costs with anesthesia.

In addition to the PET requirements in the hospital final rule, a second solution is already a law. Good Faith Estimates (GFEs) and Advanced Explanation of Benefits (AEOBs), are both foundational aspects of the No Surprises Act passed in 2020. In July, Republican and Democratic Senators sent a letter to CMS demanding the enforcement of AEOBs. Last week, House Ways & Means Republicans followed suit. This is the first critical aspect of a world where healthcare starts with a bill, rather than ending with one. They shift the burden of combining healthcare codes to estimate a price to your insurance and require that you receive a price ahead of a non-emergency service.

Most importantly, if a final bill differs from the GFE by more than $400, patients have access to a dispute resolution process. This establishes a clear system of accountability and consequences for healthcare bills that are unjustified. Enforcement of AEOBs, rather than MRF standards, is where we start pushing price transparency beyond the world of Excel sheets and actuaries.

And to make it happen, we need to standardized healthcare billing and coding

The second aspect of approachable healthcare prices is to create open-licensed bundles that combine healthcare codes into easy-to-understand services. If two patients (one young, one old) receive an MRI, they are going in a metal tube for 60 minutes: one code, one service. Easy to bill and understand.

This instantly gets more complex with a knee repair. Physical therapy will be more extensive for an older patient. There’s a solution to removing this complexity, and the building blocks are found in EDI 835 ERA transaction/claims data. These claims can be collected and then merged with the prices in the massive public transparency files. The combination is a bundle, or standard service package, where instead of 10+ codes, a patient just looks up a colonoscopy rate.

So, we're doing it ourselves with Standard Service Packages (SSPs)

Here at Turquoise Health, we’re working on this open-sourced library of healthcare bundles for any provider or insurer to use. AEOBs require a robust technical infrastructure to succeed. Improved MRF quality provides even more rates to power a patient-centric pricing engine in the near future. While our comments above are wonky, they are all part of building a true patient framework in healthcare billing. You can read all about what we're up to, more on SSPs, and true, patient-centered billing here.