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Making Sense of Price Transparency Data

Since January 1, 2021, all hospitals operating in the United States are required to publish their pricing information online, in a clear and accessible way. Known as the CMS’s new price transparency rule, this should be done both in a user-friendly format, suitable for all patients and in a comprehensive machine-readable file.

Why Is This Needed?

We all know how the healthcare system in the United States works. People with health insurance who have even deposited money in a flexible spending account, still sometimes have to dig deep into their family savings in times of health emergencies with their health. We won’t be lying if we say that millions of Americans are one hospital stay away from bankruptcy.

Until now patients learned the price they have to pay after all procedures are already done and the bill has arrived. The new federal rule tries to help with financial planning in such cases.

With the new rule, the Centers for Medicare and Medicaid Services helps patients by requiring hospitals to provide detailed pricing information on all medical procedures patients may need to undergo. That way people can plan their expenses and determine the right budget for their flexible spending accounts.

Even though the rule was delayed to ease the technology implementation burden, most hospitals still lack such price transparency.

What Seems To Be The Problem?

Let’s have a look at some numbers. All hospitals in the United States are required to publish their prices in a CSV file but in fact, 82% do not provide payer-specific rates, while 18% of them do not provide any pricing-related files at all.

As of today, 30% of the hospitals in the United States try to be compliant with the new CMS rule. We wrote try because within this 30% we observe a huge variety in the formats used – ranging from HTML, TXT, CSV, XLSX, SLSB, PDF, JSON, XLM, and even ZIP archives. Even if such files exist, they are frequently updated and sometimes introduce breaking changes of the structure, location, and/or format of the document. This naturally causes maintenance problems.

In contrast to the motivation for price transparency, pricing files are often hidden to the naked eye and require some advanced techniques to be found.

A massive complication comes from the fact that medical providers get the needed data at different stages of the treatment lifecycle and each stage introduces a different unique identifier, with a specific meaning. For example, if the data is picked when exchanged between MDs and Coders, we talk about – Current Procedural Terminology (CPT). If it is gathered post coding and before it is sent to the payer it will follow the Healthcare Common Procedure Coding System (HCPCS). On the other hand, the Diagnosis-related group (DRG) serves as a container of CPT codes and is related to specific ICDs. All this brings a lot of confusion when aiming to store all valuable data in a straightforward and easy to work with way.

Another problem that we stumbled upon is the fact that sometimes a couple of procedures apply to the same code and therefore it is easy for the information to be mixed up.

Basically, very few hospitals are still fully compliant with the correct formatting and online placement. This makes it very difficult to perform a quality comparison between procedures in different hospitals. Even if possible, it takes a huge period of time and effort. HyperAspect brings a solution to this huge mess, which is suitable for a array of the involved parties.

Who Should Be Interested?

Third-party administrators

Third-party administrators work closely with insurance companies. It is the third-party administrators, who inspect the prices in a specific medical institution and determine whether the price is adequate or not. Benefit from our simple to understand dashboards, containing search and browse capabilities.

You don’t have to make hundreds of phone calls to learn the prices of the hospitals in the state any longer. Our services automate this process and deliver detailed information that is easy to understand, thanks to price range visualizations, min and max prices, and interactive charts and maps.

Insurance companies

The claims processing procedure, which insurance companies follow is complex and requires extensive person-hours of qualified work. On the other hand, this is an important service that needs to be done with no delay. All requests need to go through medical necessity verification, technical verification of the actual claim, upcoding or down coding verification, and other steps to make sure everything is in order.

Nowadays insurance companies can have all the information to make the right decision just with a couple of clicks. Our services can save insurance companies time and effort by automating and accelerating the processing of claims. Deliver the same results through a modern and easier mechanism.

Hospitals

HyperAspect provides benefits for all your daily administrative and business work. Our solution is an excellent tool for hospitals and other medical institutions that want to evaluate their prices with the competition in the area. The healthcare industry has irreversibly fused with the economic system and now follows the same rules as traditional businesses.

You are not sure whether your price is competitive enough? Whether it is too cheap or too expensive? Perform a quick search with HyperCrawl and find where do you stand in the pricing charts. Then on, you can easily modify your pricing range to be in tune with the hospitals in your state…or set a cheaper price if this is your business model.

Patients

Patients are sometimes left out of the planning stage and get involved when the bill arrives. We believe that this is not the way how it should be done. Let’s talk about how the patients themselves could benefit from such services as well.

With our solution, patients can search for the price of a needed procedure and be aware of what they will owe even before setting foot on the premises. Price searching for a specific procedure is available even based on medical conditions.

Type in the specific condition code and learn what treatment is usually performed for this medical disorder. In the unlikely situation that you need a sequence of procedures, you can search for the lowest price for the whole course. If you are not sure about the legitimacy of the numbers we present, our pricing research can be traced back to the concrete official pricing document, so do not worry about a thing.

The Solution

At HyperAspect we have developed an AI-powered bundle of services that puts some order in the wide gamma of problematic pricing documents and their interpretation. Our solution helps in maintaining up-to-date regionally relevant payer-specific prices in a time and cost-effective manner. Deal with changing and inconsistent data with our set of predefined specialized services!

Fetching and understanding the data

As mentioned, pricing files are not easy to find. Even if the medical providers have uploaded the needed pricing files they are often almost hidden for non-IT employees. You won’t be able to find the pricing files just by following the menu of the website. Use our intelligent crawling mechanism to identify the location of the file and get the needed information. Wherever the pricing CSV (or other formats) file is hidden – we will find it and fetch it automatically from the hospital’s website.

We use machine learning algorithms to understand the valuable information contained in the listing and dispose of the data that is not of interest. This is followed by the generation of a script, which maps the important fields, containing price-related information, to our internal type of representation. Once we have imported all valuable data into our internal format it is then easier to solve any other data science operations and update the listing when changes do occur.

In addition, our system automatically filters out data that is placed in the wrong field. In our aim to process even broken files, we track transformed headers and other mistakes and deal with them in the expected way. Thanks to our solution you can detect conversion errors and facilitate their fixes.

Automation

Collecting pricing data manually is a tough job that requires specific personnel and days of work. Even if you have an effective extracting tool going through the hundreds of hospitals in the United States will still bring some troubles. We can help you to automate the whole process where you can directly receive the results you need.

With our HyperCrawl service, you can establish live data pipelines which collect provider information directly from the medical facilities’ websites. You can configure it to fetch data with a predetermined frequency and convert all valuable data from the formats we support (HTML, TXT, CSV, XLSX, XLSB, PDF, JSON, ZIP) into consistent representations.

Something worth mentioning is that when a hospital changes its pricing information our solution will understand it immediately and can perform another fetch request, get the changed fields and update the script (if necessary). This makes maintenance practically effortless and costs much lower than the common practices used today.

We try to go even further and invite you to embrace changes with effective administration of hospital profiles. Generate new hospital profiles learning from other existing ones. When it comes to the consistency of conversion profiles, you can perform automatic checks.

It is expected that the next stage of CMS’s price transparency policy will include the obligation for hospitals to provide their pricing information through APIs. With HyperAspect’s bundle of services you also receive paths to API integration with hospitals introducing such services.

Search capabilities

Our tool facilitates the searching of pricing data based on CPT or HCPCS codes. We also provide the possibility to perform searches via some nonstandard service codes. Other search criteria we support are service description, geographical location, patient type (whether we talk about inpatients or outpatients), and payer.

Based on the search query our users performed, our simple dashboard provides the count of pricing entries of each hospital, minimum and maximum prices found for the specific medical procedure in the chosen area, and other simple conclusions.

One thing we should mention – there is no limit on the number of requests that you can perform through our system. You can perform as many searches as needed to get the awaited result.

Presentation

When it comes to presentation, our solution generates easy to interpret summaries and visualizations. Thanks to our user-friendly visualization of data, our services can be used even by non-medical professionals.

You don’t have to go through all our findings to compare prices, as we facilitate the compare and contrast process in many ways. For example, we can generate price heatmaps organized by state or zip code. We also provide price distributions across payers that can be interactively filtered.

Our solution can be used even if you know only the disease and not the treatment. Users can utilize valuable literature supported DRG, ICD and map it to CPT and HCPCS codes. You can also leverage internal hospital information to extend the existing mapping from historical references.

If this new regulation seemed like a big waste of time as it is not applied as intended, we hope that with this blog post you see how you can still make it work with our help. With HyperAspect’s services, you can overcome all obstacles set by the hospital’s negligence. Find the document even if it is well hidden, get all valuable pricing information no matter the format and how many errors the file has, and visualize the data in an easy-to-understand manner, which is suitable for both medical professionals, insurance employees, and patients.