TPAs: A Piecemeal Solution To Transparency In Coverage Could Be Your Last Meal


The Transparency in Coverage Rule (TiC) already requires that companies post machine readable files (MRF) which disclose negotiated rates for every in-network provider and the historical payments to, and billed charges from, out-of-network providers.  The MRF must also include in-network negotiated rates and historical net prices for covered prescription medications, broken down by health plan or prescription issuer and by pharmacy.  The grace period for non-compliance with the first two file requirement (only allowed to those employers already working in “good faith” to comply) ended July 1, 2022.  That’s when fines to employers and health insurers of $100 per member per day were slated for enforcement.  And the Biden Administration has shown no sign that they will further delay enforcement for these two files. The pharmacy file continues to have delayed enforcement pending further guidance.

Educated employer clients of third-party administrators (TPAs) will, of course, expect that their TPAs will have provided them access to tools that deliver full compliance with the July 1, 2022, TiC requirements.  Letting those clients down just isn’t an option; an employer with 1,000 employees (representing far more health plan “members”) can be fined well over $35,000,000 per year.  A company with 5,000 employees can be fined well over $175,000,000 per year.  And the U.S. Government is very hungry for revenue.

There are companies other than ours out there offering software solutions that might deliver minimal compliance with the July 1, 2022, first phase of the MRF requirement.  But July 1, 2022, was just the beginning.  Much, much more data, in far more user-friendly formats, will soon be required.  And software solution companies who are advising TPAs to “just trust” them, because they’ll have the needed software and interfaces in the nick of time, are asking a heck of a lot.  Because if they encounter hurdles that slow them down or trip them up, a TPA’s employer clients stand to lose tens or hundreds of millions of dollars.

To put it bluntly:  If you are a TPA, a piecemeal solution to the Transparency in Coverage Rule could be your last meal.

The hurdles ahead are formidable for any technology company that does not already have what we have—a complete solution to all phases of TiC.  We worked diligently, for years, to create it and patent portions of it, and we’re very, very proud of it.

Remember, much more data will soon be required to stay compliant with TiC:  By January 1, 2023, every employer must provide employees an online shopping tool featuring 500 shoppable services and provide individual estimates of out-of-pockets costs to employees for those 500 services.  A year late, by January 1, 2024, all other procedures, drugs, durable medical equipment and any other item or service must be published, too.  It is possibly, maybe even likely, that the broader interpretation of requirements under the No Surprises Act, to allow all services to be shopped, will be required by 1/1/2023. We have all that done and ready to deploy—right now.  So, you don’t have to trust us, you can bank on us.

–Mark Galvin
Founder, Chairman & CEO, TALON


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Ensuring Compliance with the No Surprises Act and Transparency in Coverage Rule