Challenges Encountered When Using Required Machine-Readable Files From the 2022 Transparency in Coverage Rule: A Blue Cross and Blue Shield of Louisiana Case Study

OBJECTIVES: Starting July 1, 2022, the Transparency in Coverage Rule requires payers to publish Machine Readable Files (MRFs) that represent information on billing rates among providers. Blue Cross and Blue Shield of Louisiana (BCBSLA) set out to understand potential limitations and challenges healthcare consumers might encounter.

METHODS: BCBSLA retrieved selected files that payers provided. Local teams and external vendors established Extract, Transform, and Load (ETL) processes to inject large-sized MRF data (e.g., more than 100 TB) from different payers every month. Teams leveraged available MRF data to understand provider rates. Researchers used weighting methodology to allow for comparison among providers. They encountered limitations related to validity and completeness of the data and addressed them, as appropriate, to allow for early analysis.

RESULTS: Analysis of specific providers indicated significant differences among payers based on payment policies. When assessing multiple procedure reduction policies, Payer A was 108% of Payer B rates when using the information available in the MRFs. This increased to 131% of Payer B rates when considering policy differences at the claim level.

CONCLUSIONS: Transparency in Coverage Rule-mandated MRFs may not be easily accessible for the typical healthcare consumer. The BCBSLA experience highlights factors that may create challenges for consumers. Primarily, the schema of the files is difficult to ingest and access. Reimbursement knowledge is required to understand pricing methodology and develop meaningful insight. Lastly, reliance on complex data aggregation methodology is essential to develop comparisons among providers.