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Four Concrete Steps in 2024 to Navigate CMS Transparency Regulations

HealthEdge’s Regulatory Compliance Manager Maggie Brown and VP of Sales Solutions Diane Pascot recently addressed a large audience of AHIP members on an AHIP webinar that focused specifically on the rapidly evolving regulations surrounding price transparency. The two industry veterans gave attendees a fresh perspective on the evolution of multiple regulations as well as practical guidance on what payers can do in 2024 to better navigate the changing CMS regulations as they come into sharp focus this year for many payers, including the more than 130 HealthEdge customers.

This blog serves as a summary of the webinar. To listen to the full webinar, visit the HealthEdge Resources section on the HealthEdge website.

A Regulatory Refresher

The Transparency in Coverage and No Surprises Acts have both passed, but the final ruling on how health plans must implement these Acts and how they will be enforced are still evolving. New rulings, such as the Mental Health Parity Act and Advancing Interoperability & Improving Prior Authorization Acts, have emerged, and CMS recently released FAQs to help clarify how health plans must provide personalized cost sharing information for ALL items and services.

The rapidly evolving regulations can feel like a complex puzzle for many health plan leaders. But when you step back and look at the evolution of healthcare policy as a whole, it starts to make a bit more sense. The big picture is all about seeking transparency in healthcare processes and pricing, consumer protection, digital access to information and care, and the different regulations tend to build upon each other.

A puzzle with text and numbers Description automatically generated with medium confidence

While these regulations tend to build upon each other, everything is constantly evolving so health plans can no longer respond to individual rules just in time. They must understand where the policies are going and be prepared with the right technology and partners who can help them implement strategies that will support compliance long term.

What We Know: Regulatory Evolution

As regulations continue to be finalized, they seem overwhelming, but they are designed to build on one another, giving payers opportunity to leverage a stepped approach. If we approach them as building upon each other, leaving room for unexpected regulations, it optimizes the ability to successfully prepare, taking one step at a time.

4 Concrete Steps Plans Can Take Today to Ensure Readiness 

Concrete Step #1: Make sure you have the right technology, especially the right core administrative processing system (CAPS) in place and are focused on the right functions for existing and future rulings and implementation guidelines.

Your CAPS technology needs to have the structure that can pull together the right pieces of administrative data and the flexibility to support compliance as guidelines evolve. For example, with the new interoperability regulations, health plans will eventually have to show how many times each patient uses an access API in a year.

To achieve compliance with this reporting requirement, you need to start with a CAPS and a technology partner that can help you thoughtfully set up the access and structure to gather the meaningful data about individual and aggregated patient access. This must be done in a way that can be configured for any required audience or requirement.

1. Benefits administration and member management

  1. Ensuringmembers are associated with the right benefits package
  2. Properly tracking member accumulators so cost-sharing information is accurate and up-to-date

2. Provider network configuration and management

  • Seeking negotiated rates with all providers
  • Establishing processes for out-of-network providers so members aren’t surprised
  • Maintaining up to date provider directories with complete and accurate information

3. Billing and Data

  • Automated billing practices to ensure that members are held harmless under NSA criteria
  • Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs) to improve the electronic exchange of health care data and streamline prior authorization processes
  • Cost-sharing data for all items and services available online

4. Claims Processing

  • Processes to avoid, and handle provider disputes
  • Processes that build on existing claims workflows, but can generate claims information for AEOBs for members – without triggering a bill or a payment

Compliance can get a bad reputation, because the regulations and changes can lead to burdensome manualized processes. In fact, many CAPS systems require payers to pend claims. But, when you leverage flexibility and configurability within the right structures, you can retain automated processes, minimize pending, pay your providers on time, and remain compliant. Well thought out reporting and analytics can be used to monitor trends, identify trends, reduce access to care issues and ultimately improve outcomes.

Concrete Plan #2: Web-based Price Comparison Tool

According to the No Surprises Act that builds on the Transparency in Coverage Act, health plans must provide web-based and personalized cost information, allowing members to compare prices for different providers and find out what their cost-sharing responsibility will be with respect to current accumulators.

Your CAPS system should have some kind of flexible claims functionality. With HealthRules® Payer, for example, plans can call for current accurate data into basically a ‘practice’ claim without triggering an adjudication.

This is a big deal, because in most claims processes, going through the process of pulling provider and member data together would automatically trigger a payment process. And, if plans try to work-around NOT using the claims system, they can’t get the same level of up-to-date accuracy. This is important because not only does provider pricing change, but member accumulators change every time they contribute to their deductible or out of pocket max.

While the regulations relating to this requirement were passed quite a while ago, just last month, in February, more detail was released.

This is another example of how plans can take a phased approach for evolving regulations by establishing and auditing this type of a tool also gives a good opportunity to see if there are any billing/benefits changes needed for your plan to meet parity guidelines, i.e., mental health co-pays are equivalent to physical health.

Similarly, interoperability and the prior authorization enhancements will rely not only on accurate data, but the ability to assemble the data into a meaningful story.

Price Transparency Snapshot

Challenge: Provide a web-based service for members to compare pricing for specific providers with respect to their current plan and accumulators

Solution: A CAPS system with flexible claims functionality will help health plans produce accurate claim adjudication details that include member responsibilities regarding:

  1. Provider-specific payment/contract terms and fee schedules
  2. Member benefit plan data
  3. Member cost sharing based on accumulators at the time of trial claim adjudication

With the right technology, health plans can aggregate member-specific, provider, and service details according to accurate (not estimated) claims data. There is also CAPS technology available to connect this data to web-based member tools (e.g., member portals) so members can access cost information at any time and platforms through which customer service representatives can provide member-specific price comparisons to support member price comparison questions via phone.

Concrete Step #3: Advanced Explanations of Benefits (AEOB)

The Advanced Explanations of Benefits (AEOB), a key requirement introduced by the Consolidate Appropriations Act of 2021, is still pending. Guidelines are in development, with an RFI concluding last year. The AEOB will be triggered when a provider notifies the health plan that services have been scheduled, using a good faith estimate. Health plans must be able to respond with cost sharing based on that good faith estimate, which will include estimates from all providers involved in the scheduled service or procedure.

Payers need to make sure their CAPS system is prepared to meet regulations using a trial feature merged with existing EOB processes. The key piece here, again, is that they can use existing platform functionality and up-to-date, accurate information without triggering a payment.

If the scheduled service is with an out-of-network provider or facility, the EOB will note that and use qualified payment amounts to provide the anticipated cost. Plans may also have to recommend an in-network alternative to members on the AEOB.

AEOB Snapshot

Challenge: Prepare to meet AEOB requirements according to forthcoming rulemaking and implementation guidelines

Solution: A CAPS system with flexible claims functionality will help health plans aggregate details related to service codes and provider types, including:

  1. Individual services costs
  2. Episodes of care costs
  3. Individual member-level details, including current accumulator data

With the right technology, health plans can generate anticipated claims payment detail in advance of a scheduled service. A full claims adjudication process takes advantage of all configuration details, calculating accurate – and not estimated – costs without triggering a payment.

Existing CAPS features generate EOBs for configurable and automated distribution that can be combined with the detail generated by the trial claim.

Concrete Step #4: Payer to Payer Data Exchange

Health plans using HealthRules Payer already meet the required relevant standards for this regulation, including:

  • United States Core Data for Interoperability (USCDI)​
  • HL7® Fast Healthcare Interoperability Resources (FHIR®) Release 4.0.1​
  • HL7 FHIR US Core Implementation Guide (IG) Standard for Trial Use (STU) 3.1.1​
  • HL7 SMART Application Launch Framework Implementation Guide Release 1.0.0​
  • FHIR Bulk Data Access (Flat FHIR) (v1.0.0: STU 1)​
  • OpenID Connect Core 1.0

Because we focus on regulation all day every day, we are also prepared with recommended implementation guidelines, such as:  ​

  • HL7 FHIR CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) IG Version STU 2.0.0
  • HL7 SMART App Launch IG Release 2.0.0 to support Backend Services Authorization

These implementation guidelines will also help health plans prepare for the upcoming prior authorization, such as:

  • HL7 FHIR Da Vinci Documentation Templates and Rules (DTR) IG Version STU 2.0.0​
  • HL7 FHIR Da Vinci Prior Authorization Support (PAS) IG Version STU 2.0.1​

Payer to Payer Data Exchange 

Challenge: Payer to Payer Data Exchange has been expanded. The original set of requirements were deferred, and now there are structure and implementation guides for January 2027. This criteria includes HL7 and specific implementation guides.

Solution: A CAPS system and technical partner with the expertise to apply implementation guides for meaningful results

  1. Leverages existing technology for new Payer to Payer Data Exchange meeting Required Standards with the expertise to recommend the right implementation guidelines
  2. Creates meaningful information by sending and receiving the right data elements in the right configuration to ensure transparency and continuity of care for members

Key Takeaways

Regulations require us to understand the compliance requirements and the intention of each rule, how it relates to the current state of the business process, and how it impacts both the upstream and downstream processes. Each rule dives into the “why,” and health plans should seek to collaborate with technology partners to create solutions that support the requirement.

  1. New regulations build on recently passed regulations; a stepped approach will help payers stay on top of the evolution. Stay on top of all types of communication such as changing enforcement dates, FAQs, guidelines, etc., not just final rulings.
  2. Cost transparency and the proposed mental health parity regulations build toward consumer protections and updated data exchange methods. Make sure you have the data and analytics established to report on pricing for the Parity regulations. Be sure to pull your reports well in advance of the January 2025 enforcement date so you can identify and adjust any non-compliant pricing issues.
  3. The right CAPS will have the structure and configurability that help health plans prepare for and adapt to ever-evolving regulations. Make sure you have the right CAPS technology and are focused on the right functions for existing and future rulings and implementation guidelines. Your CAPS needs to have the structure that can pull together the right pieces of administrative data and the flexibility to support compliance as guidelines evolve. Plans will not be able to meet the evolving regulations without technology that can ensure compliance and automation.
  4. Keep the big picture in mind and look for the next-best step that works for your health plan. Make sure your CAPS technology meets required standards for upcoming interoperability and prior authorization regulations. Ensure you have a good technology partner who can help you start to plan your implementation guidelines and start planning now.

To learn more about how HealthEdge solutions can help your organization navigate the evolving CMS regulations, visit