On Oct. 6, federal regulators finalized updates to the Transparency in Coverage rule, which governs the pricing data health insurers and employer health plans must publish. While the rule places no new requirements on ASCs, the changes could affect how surgery centers benchmark rates, negotiate with payers and make their cost case to employers.
Here are five things to know:
1. The rule targets insurers, not ASCs. The final rule, issued jointly by HHS, the Labor and the Treasury departments, amends the 2020 price transparency rules for health plans and takes effect Dec. 7. ASCs have no new reporting obligations under it, but surgery centers’ negotiated rates already appear in the insurer files the rule overhauls.
2. Comparing ASC and hospital prices may get easier. Insurers will now publish one in-network rate file per provider network rather than one per plan. CMS said the change aligns payer data with how hospitals report under the Hospital Price Transparency rules, making it easier to compare the two sets of files. For ASCs, that could strengthen the data behind the case that outpatient surgery centers offer lower prices than hospital outpatient departments.
3. Rate benchmarking data should be cleaner. Insurers must remove rates for providers unlikely to perform a given service, which CMS called a major driver of oversized files, and publish a new utilization file listing providers that actually billed and were paid for services. ASC rates are already public in these files, but less noise could make it easier for operators and consultants to benchmark against competitors ahead of payer negotiations.
4. More out-of-network data will be published. Insurers will report out-of-network allowed amounts by market type and lower the minimum reporting threshold from 20 claims to 11, over a longer reporting period. CMS expects the changes to significantly increase the amount of out-of-network data available to the public.
5. Most changes kick in during 2027. Changes to the in-network rate and out-of-network files apply five months after publication, and the new taxonomy, utilization and text files apply 11 months after publication. Insurers will also update rate files quarterly instead of monthly, which regulators estimate will save plans and issuers about $174.5 million annually beginning in the
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
