A reference based pricing plan having direct provider contracts is by definition a “network” plan. (See definition of “in-network” in Code of Federal Regulations, 147.210, XII) In that instance a plan sponsor must publicly display in-network information containing name, CPT code and negotiated rate and fee schedule rates.
This public information will be useful in many ways. For example, a sampling of Reference Based Pricing plans in a given geographic area will provide an indication of which providers are more apt to contract with these plans as well as the level of reimbursement generally allowed. This new government mandated price transparency rule will be a valuable source of competitive information providers can access to determine pricing charged by their competitors.
“To meet the [Transparency in Coverage] requirements that will be enforced starting on July 1, 2022, plans and issuers must create two files — one to disclose in-network provider rates for covered items and services and another to disclose out-of-network allowed amounts and billed charges for covered items and services.” MORE >>
Foley & Lardner LLP
