Claims Data

CMS has made it clear in their FAQs that providers should populate payer-negotiated rates in the MRFs based on actual contracted amounts and fee schedule amounts, rather than using historical claims reimbursement information. This distinction is crucial for compliance. Payer-specific negotiated rates included in MRFs should not be derived from claims data.

Separate from negotiated rates though, claims data does serve three significant purposes related to price transparency requirements:

1. Capturing all Services Provided

Outpatient soft-coded CPTs are procedures coded after services are rendered and are typically found in clinical data within a patient accounting system. These codes appear on final claims after bill edits associated with specific revenue codes such as 360 (operating room services) or 481 (cardiology services).

To incorporate soft-coded CPTs into MRFs, Turquoise reviews a six-month period of billed claims to identify soft-coded procedures. These procedures, often high-cost surgeries, are typically not found in the CDM but do have negotiated rates in commercial payer contracts and fee schedules. We add these identified services to the MRF to ensure comprehensive service capture. You can read more about our soft-coded CPT processes here.

2. Creating Estimated Allowed Amounts (Effective 1/1/25)

When a percentage-based rate or algorithm is reported in the MRF, CMS requires an estimated allowed amount, which is based on historical reimbursement data.

The Turquoise process for reporting the estimated allowed amount involves calculating the average reimbursement amount by service and payer. The values are extracted from claims data and we ensure that the service was billed at least 10 times to maintain compliance with the CMS cell suppression policy. To facilitate this, we use claims and remittance files in 835 or 837 formats.

3. Publishing Shoppable Service Packages or a Patient Estimator Tool

Claims data helps in creating shoppable service packages to fulfill the shoppable services requirement of the final rule. A patient estimate tool allows patients to estimate their out-of-pocket costs for various services based on historical claims data.

By leveraging claims data for these purposes, Turquoise Health ensures that the MRFs are accurate, comprehensive, and compliant with CMS regulations, ultimately enhancing transparency and usability for both hospitals and patients.