The Qualifying Payment Amount (QPA) plays a significant role in the No Surprises Act (NSA). When managing compliance with the NSA, it is essential to understand what the QPA is and how it impacts payors, providers, and members. Several common challenges in calculating Qualifying Payment Amount accurately include:

• The complexity of federal regulations, requirements, and interpretation of compliance
• Infrastructure and technology limitations due to the size of the files
• Access to dedicated and qualified industry personnel across various areas of expertise   

This blog post offers a QPA 101 primer, answering several frequently asked questions.

How is QPA defined under the NSA?

The Qualifying Payment Amount or QPA is a plan鈥檚 median contracted rate for the same or similar services when provided by same or similar providers in the same geographic market, adjusted for inflation.  

Generally, the NSA mandates that QPA be used to calculate member cost sharing, and as one of the items Independent Dispute Resolution Entities are asked to consider when making payment determinations in the arbitration process.

How is the QPA calculated?

 The No Surprises Act requires that CMS audit payors to ensure that QPA is calculated and determined appropriately. As a result, deriving accurate QPA schedules is critical to NSA compliance.  

The July 2021 original Interim Final Rule as well as subsequent guidance released by the U.S. Department of Labor, the Department of Health and Human 成人视频, the Department of the Treasury, and CMS, include the methodology for calculating QPA that Health Plans are required to follow. This includes three main steps: 

1. Determine if the plan has sufficient information to perform the calculation

Plans must use contract rates in effect as of January 31, 2019, to calculate QPA. To have a sufficient amount, a plan or issuer must have at least 3 contract rates for the service (provided by a similar provider in the correct geographic market).

If the plan does not have sufficient information, the plan must calculate the QPA using the median contract rate for the first sufficient information year thereafter.  

In cases where a plan does not have sufficient information to calculate a median contracted rate, the plan must determine the QPA using an eligible database. 

2. Determine the median contracted rates

The following factors must be considered: 

Contracted Rates

The contracted rates for all plans of the plan sponsor (or administering entity, if applicable) for the insurance market. 

Single case agreements are not considered contract rates for the purpose of calculating QPA.

Insurance Market

 Insurance markets include: 

• Individual market (excludes short-term, limited-duration insurance) 
• Small group market 
• Large group market 
• Self-funded plans 

Any plan or coverage that is not a 鈥済roup health plan鈥� or 鈥済roup or individual health insurance coverage鈥� offered by a 鈥渉ealth insurance issuer鈥� is not to be included for the purposes of determining the QPA.

Same or Similar Items or 成人视频

The health care items or services billed under the same or similar service code or comparable code under different procedural code system. 

Provider in the Same or Similar Specialty 

The practice specialty of a provider as identified by the plan consistent with the plan鈥檚 usual business practice.

Geographic Region 

Geographic requirements are broken down into a primary definition and two alternate definitions.  

For non-air ambulance items and services, these are defined as follows: 

• Primary definition. This is one region for each MSA in the state and one region consisting of all other portions of the state. 
• First alternative. This is one region consisting of all MSAs in the state and one region consisting of all other portions of the state. 
• Second alternative. This is one region consisting of all MSAs in the Census division and one region consisting of all other portions of the Census division.

3. Determine the median rate for each combination (service + provider type + geographic area) to identify the applicable QPA for each

This is a topic that has been in flux over the past two years, due to litigation brought by the Texas Medical Association (TMA).  All four TMA lawsuits have been resolved, requiring plans to revise some aspects of how they calculate the QPA by, for example, excluding bonuses, incentives, or other potential increases when determining the contract rate for calculating QPA.

How does the QPA factor into Member Cost Sharing? 

For surprise bill claims subject to the NSA, the member鈥檚 cost share is determined before the claim is paid, and it can鈥檛 be changed even if the plan ends up paying a higher amount to the provider for those covered services. Under the NSA, the member鈥檚 cost share is determined using the lesser of billed charges or the QPA.  

For fully insured plans subject to state surprise bill laws, or ERISA plans that have opted in to such laws, the recognized amount may be determined by the state-mandated process. Additionally, in these circumstances provider-plan disputes over reimbursement will be managed under state surprise bill laws.

How else is QPA used in the Process?  

In addition to being used in the member cost share determination process, plans must disclose QPA to the provider at the time initial payment is made on a surprise bill.  

Additionally, Independent Dispute Resolution Entities (IDREs) are required to consider the QPA (in addition to other factors) when arbitrating surprise bill reimbursement disputes between providers and payors.  

While not mandated by NSA for any other uses, many payors are using the QPA to make initial payments to providers for surprise bill services rendered.

Next Steps 

NSA compliance can be complex, but you don鈥檛 have to navigate the complexities alone. We are here to support you. To learn more about how we can help bend the cost curve, download our white paper or visit our website.

Disclaimers: The information provided on this website does not, and is not intended to, constitute legal advice; instead, all information, content, and materials available on this site are for general informational purposes. If you have questions about how the No Surprises Act applies to your organization, please consult your legal counsel. 

The Sober Landscape of Healthcare in Rural America

Rural healthcare organizations are grappling with dire financial pressures. According to a 2024 study by the Chartis Center for Rural Health¹:

• Over a 12-month period, the percentage of rural hospitals with a negative operating margin increased from 43% to 50%.
• More than half of independent rural hospitals (55%) and 42% of health system-affiliated rural hospitals are operating at a loss.

At the same time, healthcare leaders are contending with labor shortages, declining rural populations, and decreasing reimbursements. All of these factors combine to fuel a downward cycle. In many cases, rural hospitals and health systems often resort to closing service lines.

Over a ten-year period (2011 to 2021), for example, nearly 25% of rural obstetric units closed.² Meanwhile, between 2014 and 2022, 382 rural hospitals stopped providing chemotherapy services.³

As healthcare options dwindle, patients must travel further, with many seeking services at urban care facilities. For instance, a study conducted at the University of Minnesota found that rural women diagnosed with breast cancer traveled on average nearly three times as far for radiation treatment as women living in urban areas.⁴ Conventional radiation therapy requires treatment five days per week for 5 to 7 weeks at a time. This means that the average rural woman logs more than 2,000 miles over the course of treatment.

Across the nation, growing numbers of rural healthcare organizations are being forced to cease operations completely, leaving 鈥渉ealthcare deserts鈥� in their wake. Since 2014, close to 200 rural hospitals have closed, leaving communities without access to emergency departments or inpatient care.⁵

The Center for Healthcare Quality & Payment Reform estimates that in 2024, over 30% of all rural hospitals (around 700 facilities) are at risk of closing due to financial problems and over half (364) are at immediate risk of closing.⁶ Every closure deprives communities of essential healthcare services, and triggers economic disruption as jobs are eliminated.

The impact of this healthcare crisis can鈥檛 be ignored鈥�20% of Americans live in rural areas and research suggests these individuals are at higher risk of death from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke than their peers who live in urban areas.⁷ At the same time, only around 9% of U.S. physicians practice in rural areas.⁸

Price Transparency Data 鈥� The Fuel for a Rural Healthcare Renaissance

In recent years, opaque healthcare pricing in the United States has gained broader visibility. Regulatory changes like the Hospital Price Transparency Rule⁹ and the Transparency in Coverage Rule¹⁰ are generating new opportunities to positively impact the financial performance and operational costs at rural healthcare organizations.

With these price transparency rulings, much attention has been given to conforming to CMS-mandated machine-readable file (MRF) requirements and submissions. At many rural healthcare providers, a primary focus has been on securing the staffing and expertise needed to ensure compliance.

Price transparency data collection isn鈥檛 just a compliance exercise, however. This information holds significant strategic value for organizations. When rural healthcare providers have visibility into how much competitor organizations are paid for the same services, they suddenly have greater power to negotiate more favorable prices and to start rebuilding their own financial wellbeing.

By leveraging the insights that exist within price transparency files, rural healthcare organizations can:

• Leverage benchmarks to improve pricing strategies and enhance competitiveness by comparing rates across payers and geographies
• Identify growth opportunities based on utilization trends and highly utilized services
• Optimize strategic planning process to plan effectively to meet demands for the future

Conclusion

To reinvent America鈥檚 rural healthcare infrastructure, hospitals and health systems must move beyond merely complying with price transparency rulings. By shifting their attention to the insights within this data, organizations can develop strategies that will enable them to care for their communities in financially sustainable ways.

In our next blog post, we will explore how rural healthcare providers can uncover new sources of competitive advantage in the sea of price transparency big data.

All data within CompleteVue is based on publicly available price transparency machine readable files, Medicare rates, and third-party benchmark data.

¹ Chartis. (2024, February 13). Unrelenting pressure pushes rural safety net into uncharted territory | Chartis. Healthcare Advisory 成人视频 and Analytics | Chartis. 

² Chartis. (2024, February 13). Unrelenting pressure pushes rural safety net into uncharted territory | Chartis. Healthcare Advisory 成人视频 and Analytics | Chartis. 

³ Chartis. (2024, February 13). Unrelenting pressure pushes rural safety net into uncharted territory | Chartis. Healthcare Advisory 成人视频 and Analytics | Chartis. 

⁴ Plain, C. (2020, February 11). U.S. rural breast cancer patients must routinely travel long distances for treatment – School of Public Health – University of Minnesota. School of Public Health. 

⁵ Center for Healthcare Quality and Payment Reform. (2024). RURAL HOSPITALS AT RISK OF CLOSING. 

⁶ Center for Healthcare Quality and Payment Reform. (2024). RURAL HOSPITALS AT RISK OF CLOSING. 

⁷ About rural health. (2024, May 16). Rural Health. 

⁸ Calling All Country Doctors: Study Challenges assumptions about rural physician recruitment. (n.d.). The University of Vermont. 

⁹ Hospital Price Transparency | CMS. (n.d.). 

¹⁰ Transparency in Coverage Final Rule Fact Sheet (CMS-9915-F) | CMS. (2024, November 22). 

January 28, 2025 鈥� 成人视频 (鈥湷扇耸悠碘�� or the 鈥淐ompany鈥�) (NYSE: MPLN), a leading provider of technology and data solutions that improve affordability, quality and transparency in healthcare, announced today that it will release its fourth quarter and full year 2024 financial results on Tuesday, February 25, 2025, and hold its conference call that morning at 8:00 am Eastern Time.   

To join the conference call, please pre-register using the link below. Participants who pre-register will receive a calendar invitation with call access details including a unique pin. Pre-registration may be completed at any time up to and following the call start time. 

To pre-register, go to:听 .听

A live webcast of the conference call can be accessed through the Investor Relations section of the Company鈥檚 website at . Participants should join the webcast ten minutes prior to the start of the conference call. The earnings press release and supplemental slide deck will also be available on this section of the Company鈥檚 website. 

For those unable to listen to the live conference call, a replay will be available approximately two hours after the call through the archived webcast on the Investor Relations section of the Company鈥檚 website. For those requiring operator assistance please dial (404) 975-4839 or (833) 470-1428. The access code is 940787. 

About 成人视频 

成人视频 is committed to bending the cost curve in healthcare by delivering transparency, fairness, and affordability to the US healthcare system. Leveraging sophisticated technology, data analytics, and a team rich with industry experience, 成人视频 interprets clients鈥� needs and customizes innovative solutions that combine its payment and revenue integrity, network-based, data and decision science, and analytics-based services. 成人视频 delivers value to more than 700 healthcare payors, over 100,000 employers, 60 million consumers, and 1.4 million contracted providers. For more information, visit鈥�multiplan.com.

For brokers, this isn鈥檛 just a challenging time鈥攊t鈥檚 an opportunity to make a real impact by offering creative, data-driven strategies, and helping employers tackle the pressures head-on to achieve better outcomes for their employees.

Let鈥檚 dive into six key trends impacting the healthcare payor space in 2025 and how brokers can empower their clients to not just adapt, but thrive, in the year ahead.

1. Rising Healthcare Costs

Healthcare costs are projected to , driven by specialty drugs, GLP-1 medications, inflation, and wage growth. Employers must make tough decisions to balance budgets, while employees face growing out-of-pocket costs. Unfortunately, untreated chronic conditions are becoming more common as employees delay care to save money, leading to absenteeism and lost productivity.

A recent survey found that are struggling with the impact of rising healthcare costs on wages and benefits. Many are shifting more costs to their workforce while also prioritizing health equity initiatives and strategies to manage high-cost claims, reflecting a broader evolution in how organizations approach employee health and well-being.

2. The Role of AI and Advanced Data Analytics

are changing the game in healthcare, allowing employers to spot high-cost trends and act quickly. Predictive analytics, for example, can flag employees who might be at risk for chronic conditions, making early intervention possible. Meanwhile, tools that streamline claims management and personalize care plans make the process smoother and more efficient.

For brokers, partnering with companies that offer these data-driven solutions is a smart move. By using predictive models to identify trends or tapping into analytics to uncover cost-saving opportunities, brokers can position themselves as trusted advisors. These solutions don鈥檛 just help鈥攖hey deliver measurable results employers can count on.

3. Transparency and Compliance

regulations are pushing employers to examine their health plans more closely, ensuring they fully understand price transparency and are prepared to meet the requirements of compliance. Falling short on these regulations carries the risk of significant fines and also the potential for reputational damage for all involved.

Brokers equipped with innovative tools like PlanOptix can make a real difference. By helping employers make sense of complex data, brokers can uncover opportunities to help their clients identify cost-effective providers, negotiate better direct contracts and optimize their networks.

4. Virtual Health and Point Solutions

Employers are increasingly investing in virtual health and behavioral health programs to address workforce needs. A 2023 Teladoc Health survey found , focusing on mental health challenges like anxiety, depression, and burnout, as well as chronic conditions such as diabetes and hypertension.

To tackle these challenges, employers can implement targeted programs and point solutions that improve employee well-being, enhance productivity, and reduce absenteeism. By using analytics, brokers can assess program performance and ensure employers get the most out of their investments.

5. Innovation in Plan Design

Employers are looking for fresh ways to control costs without compromising employee satisfaction. Standout strategies include Individual Coverage Health Reimbursement Arrangements (ICHRAs), direct provider contracting, and cost containment models.

ICHRAs give employees more freedom to choose individual insurance plans while offering cost predictability for employers.  Direct provider contracting eliminates the middleman by allowing employers to negotiate directly with healthcare providers for better rates and quality care. Value-driven healthcare plans (VDHPs) primarily focus on incentivizing quality care through payment structures tied to patient outcomes, while Reference-Based Pricing (RBP) focuses on cost containment by setting a fixed price ceiling for healthcare services, often based on Medicare rates, to limit what providers can charge, with the goal of reducing overall healthcare spending for employers and patients; both models aim to improve healthcare value but through different mechanisms – quality-focused incentives versus price-based limitations. Brokers who understand and implement these options can deliver customized solutions that benefit both sides.

6. Focus on Employee Engagement and Preventive Care

Preventive care is becoming the backbone of employer health strategies. Programs like smoking cessation, fitness challenges, and stress management improve health and reduce long-term costs. Brokers can make these programs even more effective by pairing them with flexible networks like PHCS, which gives employees access to quality care without restrictions.

Highlighting the return on investment for preventive care鈥攕uch as reduced absenteeism and healthier employees鈥攃an make a compelling case for integrating wellness initiatives into benefits plans. Sharing success stories and data can help employers see the true value of these efforts.

Moving Confidently into 2025

The healthcare challenges of 2025 demand creative thinking and practical solutions. Rising costs, new regulations, and shifting employee needs mean employers are looking for brokers who can provide clear, actionable strategies. By addressing these issues holistically, brokers can help their employer clients create healthier, more productive workplaces.

Now is the time for brokers to step up. With the right tools, insights, and partnerships, they can deliver smarter, more sustainable healthcare solutions while positioning themselves as trusted advisors and driving better outcomes for employers and their teams.

For several years, the federal government has taken steps to increase price transparency in healthcare, with the hope that better access to data will benefit consumers and other key stakeholders. 

In 2021, to disclose pricing information online for every service, drug, and item they provide. This includes the prices that hospitals have negotiated with insurers and the amounts that patients paying cash for services would be charged.

to learn how PlanOptix turns price transparency data into usable information for healthcare brokers, payers, and employers.

Similar rules were then created for many group health plans and issuers of group or individual insurance. Since July 2022, the has required insurers and large employers to publish machine-readable files (MRF) which include in-network rates for covered items and services, as well as allowed amounts and historical billed charges for providers who are out of network.

Public policy makers hoped that improved access to this information would support better health insurance network negotiations and market positioning, help the healthcare sector attain its access and cost goals, and enable various healthcare players to make data-driven decisions. The healthcare industry is still collectively striving to achieve this vision.  

The Rocky Road of Machine-Readable Files and Healthcare Pricing Data 

To derive value from healthcare pricing information, users must have confidence in the integrity and completeness of the data. Unfortunately, data quality varies widely across different payers and locations. Key challenges include: 

• Massive data volumes. Price transparency mandates have resulted in an unprecedented amount of complex data that requires extensive validation and evaluation before it can be used for practical applications. This is time-consuming work. 

• Low data quality. No standardized measures exist to assess the quality of price transparency data in MRF. is work that is usually done at the organizational level. Some hospitals and insurers have stronger data governance cultures than others.  

• Poor data integrity. recently analyzed pricing data from 2,000 hospitals and found only around one-third (34.5%) were fully compliant with all aspects of the Hospital Price Transparency Rule.

Healthcare Price Transparency Solutions Can Help, But Not All are Created Equal 

To make it easier to work with publicly available healthcare price transparency data, many technology vendors have developed tools and platforms. Those solutions, however, are only as good as the underlying data. The undeniable reality is that cleaning up healthcare pricing information is no simple task. Not only are the volumes of information enormous, but the .

For example, within the MRFs from hospitals and insurers, the payer name may be included, but not the associated plan name. It鈥檚 common for price data to be represented as a formula instead of a dollar amount. The fields for negotiated rates may contain zeros, asterisks, or blanks.  

The formatting of the data files can also be problematic. For instance, some hospitals and insurers post multiple files, even though the federal mandate requires a single file. Another issue is that files may be created in 鈥渢all format鈥� rather than 鈥渨ide format.鈥� With tall formatted files, the same item or service is repeated in multiple rows, instead of allocating one row for each item or service. This results in large volumes of repetitive information. It also makes it challenging to compare prices or identify missing price data.  

Healthcare price transparency solution vendors may assert that their data quality is high, but how true are their claims? Some companies simply jettison large portions of their data sets because they鈥檙e too complicated to clean up. While the remaining information may look sound, it鈥檚 only a fraction of the original data set.

A Tool for Informed Decision-Making

PlanOptix transforms healthcare price transparency data into usable information that healthcare brokers, payers, and employers can trust. PlanOptix is unique because the solution includes a Data Usability Rating. In addition, PlanOptix users can benchmark pricing data against Medicare rates. This is important in a world where hospitals don鈥檛 follow a standard formula for setting prices and aren鈥檛 required to reveal markups on the services or supplies they purchase. Since chargemaster data varies widely, it isn鈥檛 a useful benchmark. 

Although Medicare pricing is subject to change, it鈥檚 still a logical benchmark that is familiar to everyone in the industry. Medicare is used so widely throughout the United States healthcare system that , reducing the time and resources needed to negotiate contracts. 

The objective assessment of data quality offered by PlanOptix means you can make important decisions about healthcare costs with confidence.  

about how PlanOptix provides actionable insights into data quality and coverage.  

成人视频 consolidates cloud infrastructure to establish a scalable foundation for growth, bring new products to market faster and better support its clients and the patients and members they serve with solutions that improve affordability, quality, and transparency.

Jan. 13, 2025 鈥� 成人视频 (NYSE: MPLN), a leading provider of technology and data solutions that improve affordability, quality and transparency in healthcare, will consolidate its cloud infrastructure on Oracle Cloud Infrastructure (OCI) to support its previously disclosed digital transformation. OCI will also help 成人视频 better support its clients鈥� needs by improving efficiency and creating a more flexible infrastructure that meets evolving market demands.

鈥淢igrating to OCI is critical to achieving our vision and will enable us to leverage our expertise and data to deliver new solutions that serve a broader set of healthcare stakeholders,鈥� said Travis Dalton, President and Chief Executive Officer of 成人视频. 鈥淥ur clients will be able to better serve their patients and members with modern solutions.鈥�  

成人视频 will begin its migration to OCI with a 鈥渓ift-and-shift鈥� of its existing on-premises workloads, including a large Oracle Database footprint. OCI helps make cloud migrations faster and lowers risk by minimizing application changes while maximizing infrastructure price-performance. Over time, 成人视频 plans to move workloads currently on other platforms to OCI to take advantage of significant cost savings and performance gains. 听鈥淎s we evaluated our options, the team compared current state, other vendor alternatives, and Oracle鈥檚 next-generation cloud. The winner was clear 鈥� OCI provides best-in-class security with the performance, technical flexibility, and superior economics we need to rapidly innovate to meet our clients鈥� needs,鈥� said Michael Kim, Chief Information Officer of 成人视频.

鈥淗ealthcare organizations around the world are increasingly realizing the value of migrating to the cloud to enable greater security, agility, and innovation,鈥� said Karan Batta, Senior Vice President, Oracle Cloud Infrastructure. 鈥淏y selecting OCI, 成人视频 gains a cloud partner with significant healthcare industry expertise, compelling price-performance advantages, and a proven track record of protecting the world鈥檚 most sensitive data. OCI provides the foundation 成人视频 needs to accelerate the realization of its vision and take advantage of the latest developments in analytics and AI.鈥� 

About 成人视频

成人视频 is committed to bending the cost curve in healthcare by delivering transparency, fairness, and affordability to the US healthcare system. Leveraging sophisticated technology, data analytics, and a team rich with industry experience, 成人视频 interprets clients鈥� needs and customizes innovative solutions that combine its payment and revenue integrity, network-based, data and decision science, and analytics-based services. 成人视频 delivers value to more than 700 healthcare payors, over 100,000 employers, 60 million consumers, and 1.4 million contracted providers. For more information, visit .

The partnership strengthens the distribution of solutions that unlock value and improve decision-making efficiency, supporting providers, payors, and the broader healthcare ecosystem.

January 10, 2025 鈥� 成人视频 (鈥湷扇耸悠碘�� or the 鈥淐ompany鈥�) (NYSE: MPLN), a leading provider of technology and data solutions that improve affordability, quality and transparency in healthcare, today announced an agreement with J2 Health, a cloud-based software solution that optimizes provider network performance. This strategic agreement will support 成人视频鈥檚 network optimization strategy, providing tailored solutions and resource efficiency that ultimately reduces healthcare costs for payors.

鈥淛2 Health shares the same goal as 成人视频 in creating solutions that combine technology, data and insights, which in turn impact cost, transparency and quality in the healthcare ecosystem.鈥� said Travis Dalton, President and Chief Executive Officer of 成人视频. 鈥淭his agreement aims to unlock that value, which will ultimately drive better pricing outcomes and lower costs for our providers by increasing efficiency and reducing medical spend, allowing them to focus on higher quality, lower cost care.鈥�

With over 40 years of experience, 成人视频 contracts with over 1.4 million healthcare providers, providing services that identified $22 billion of potential medical cost savings annually on behalf of more than 700 payors and their 100,000 employer customers. J2 Health鈥檚 cloud-based software solution will enhance and deliver best-in-class network capabilities for payors by reducing the lead time and cost of decision-making. The platform complements 成人视频鈥檚 Network and Data & Decision Science services using its Network Management capabilities by identifying network gaps and enabling improvements for network adequacy, marketability and accuracy. With the agreement, 成人视频鈥檚 clients will benefit from enhanced network configuration, transparency and analytics capabilities that align with industry standards and optimize network performance for healthcare payors and their members.

鈥淣etwork intelligence and optimization are critical tools for improving the cost, quality and experience of US healthcare,鈥� said Josh Poretz, Founder and CEO of J2 Health. 鈥淭his strategic agreement between J2 and 成人视频 is a big step in delivering the insights the industry needs to be successful.鈥�

About 成人视频

成人视频 is committed to bending the cost curve in healthcare by delivering transparency, fairness, and affordability to the US healthcare system. Leveraging sophisticated technology, data analytics, and a team rich with industry experience, 成人视频 interprets clients鈥� needs and customizes innovative solutions that combine its payment and revenue integrity, network-based, data and decision science, and analytics-based services. 成人视频 delivers value to more than 700 healthcare payors, over 100,000 employers, 60 million consumers, and 1.4 million contracted providers. For more information, visit .

ESRD and Medicare Advantage

Regardless of their age, most ESRD patients are eligible for Medicare Advantage. Medicare Advantage plans are reimbursed through the federal government by the Centers for Medicare and Medicaid 成人视频 (CMS). In order for the reimbursement to occur, CMS must designate the member as having ESRD. If the member is not correctly identified as having ESRD, the plan will not be reimbursed.

ESRD premium restoration solutions help ensure Medicare Advantage plans are properly reimbursed for ESRD patients by identifying members with missing ESRD statuses and restoring the premiums. However, because of the low number of ESRD patients, plans often underestimate the potential impact of using an ESRD premium restoration solution and decide against using one. The following suggests that these plans should reconsider their decision:

• Providing care to ESRD beneficiaries, particularly dialysis treatment, is very expensive. The to be approximately $72,000 to $88,000 per year. The cost per session ranges from approximately $250 to more than $350 per session with three sessions typically needed per week.
• Medicare spending on ESRD is increasing. , Medicare is expected to pay approximately $6.7 billion in total payments to ESRD facilities in 2024, up from $5.4 billion in 2023.
• less than 1% of the total Medicare population but account for 7% of Medicare spending.
• While the exact difference in premiums depends on the specific Medicare Advantage plan and geographic location, our data indicates the Medicare Advantage premium per ESRD member per month is generally more than $5,000 more than the average Medicare Advantage premium.

How the ESRD Process Ideally Works

In an ideal world, the ESRD process works as follows:

• The ESRD patient visits a dialysis clinic for treatment.
• The dialysis clinic or submitting authority completes a 2728 form, which is primarily a nephrologist’s attestation to CMS that a patient is eligible to receive ESRD Medicare benefits, and submits this to CMS.
• CMS is alerted to the patient鈥檚 ESRD status and an ESRD indicator flag is turned on that will adjust the premium for that patient.
• The plan then receives a higher premium for covering these patients.

Opportunities for the ESRD Process to Break Down

While the process doesn鈥檛 seem complicated, there are several reasons it breaks down:

• Members have ESRD diagnoses that the plan never knew about.
• The dialysis clinic or provider doesn鈥檛 complete the 2728 form or sends incomplete or incorrect forms.
• The clinic saves the form, but never 鈥渟ubmits鈥� it to CMS.
• The flag is temporarily turned off and not turned back on鈥攆or example, because the member went to hospice for a period of time.
• CMS fails to set the flag or had inaccurate dialysis start date.

ESRD Premium Restoration 成人视频

ESRD Premium Restoration 成人视频 dig through the plan鈥檚 data to identify potential ESRD patients and compare the findings with CMS data. If there is a discrepancy, the service works with CMS to correct it so the plan is reimbursed with the higher premium. Adjustments can be made going back seven years.

ESRD Premium Restoration Results

Our relationships with dialysis centers and our proven processes with CMS separate us from other ESRD vendors and contribute to our success. One hundred percent of our ESRD clients with more than 2,500 Medicare Advantage members have had premiums restored.

Several of our clients see results with our ESRD Premium Restoration service in just a few months. For one plan with 230,000 members and multiple lines of business, we restored $4 million in seven months.

Another plan with 100,000 members worked with us to restore $3 million in 12 months.

Similar to our Medicare Secondary Payer Validation and Premium Restoration service, our ESRD service delivers successful results for small health plans as well as large. One of our newest clients has only 10,000 members, and in just two months, we restored over $300,000 for that plan.

Strong Partner for Medicare Advantage Plans

In addition to our ESRD service, we offer other payment and revenue integrity services such as editing. We also offer network building services, helping Medicare Advantage plans expand existing networks and fill in network gaps to maintain CMS adequacy. Learn more about how we can work together to strengthen your Medicare Advantage plan.

This new platform provides enriched publicly available price transparency data to enable providers to gain actionable insights for improved strategic financial action.

December 12, 2024 鈥� 成人视频 (NYSE: MPLN) (鈥湷扇耸悠碘�� or the 鈥淐ompany鈥�), a leading provider of data-driven cost management solutions that deliver transparency and promote fairness, quality and affordability to the U.S. healthcare industry, today announced the launch of CompleteVue, a modern software platform built using publicly available price transparency data that provides advanced analytics to help health systems and providers gain insight into the healthcare market.  

Recent legislation has brought incremental improvements in healthcare price transparency, but providers are often struggling to turn the complexities of large sets of unmanageable data into actionable insights and valuable gains. With the launch of CompleteVue, 成人视频 is complementing the recent legislation by providing expertise and technology to advance cost transparency and clarity in healthcare, enabling providers to focus on delivering high-quality care for patients.  

A unique product in the marketplace today for healthcare providers, CompleteVue makes sense of the billions of public records of healthcare pricing within seconds. CompleteVue can be used to not only analyze and benchmark market position, but also review critical insights and trends on market share and highly utilized services. CompleteVue further empowers providers to compare rates across payors and geographies. With 成人视频鈥檚 CompleteVue solution, healthcare providers can efficiently access this data to improve pricing strategies, identify expansion and growth opportunities, and optimize strategic planning.   

鈥淩ural healthcare is at an inflection point and its success is vital to the healthcare market as more than 80% of rural America is medically underserved,鈥� said Travis Dalton, President and Chief Executive Officer of 成人视频. 鈥淲ith our recent partnership with the National Rural Health Association announced in September and the delivery of this integral solution to empower providers, we are uniquely positioned to transform rural healthcare as we understand the common market pressures and demands providers face, and we want to help.鈥�   

CompleteVue accompanies 成人视频鈥檚 award-winning existing suite of tools like PlanOptix^TM, a price transparency solution geared towards healthcare payors, brokers and TPAs. From the provider to the patient, 成人视频 is advancing price transparency within the market to bend the cost curve for all. 

鈥淐ompleteVue was developed as part of 成人视频鈥檚 continuing efforts to provide innovative solutions that drive positive change across all stakeholders in the healthcare ecosystem, by bringing market efficiency to an otherwise opaque healthcare marketplace,鈥� said Jerry Hogge, Chief Operating Officer at 成人视频. 鈥淐ompleteVue is a self-service platform that can be utilized by any provider to harness the insights provided by price and transparency for the services they deliver, which ultimately will improve quality and value of care for all.鈥� 

The launch of CompleteVue is but one part of 成人视频鈥檚 growth initiative and further expands the addressable market for its innovative healthcare cost management and tech-enabled solutions that improve access, affordability and quality of healthcare. Learn more about CompleteVue on 成人视频鈥檚 website.  

All data within CompleteVue is based on publicly available price transparency machine readable files, Medicare rates, and third-party benchmark data. 

About 成人视频鈥�鈥赌�&苍产蝉辫;

成人视频 is committed to bending the cost curve in healthcare by delivering transparency, fairness, and affordability to the US healthcare system. Our focus is on identifying medical savings, helping to lower out-of-pocket costs, and reducing or eliminating balance billing for healthcare consumers. Leveraging sophisticated technology, data analytics, and a team rich with industry experience, 成人视频 interprets clients鈥� needs and customizes innovative solutions that combine its payment and revenue integrity, network-based, data and decision science, and analytics-based services. 成人视频 delivers value to more than 700 healthcare payors, over 100,000 employers, 60 million consumers, and 1.4 million contracted providers. For more information, visit鈥�. 

Forward Looking Statements

This press release contains forward-looking statements. These forward-looking statements can generally be identified by the use of forward-looking terminology, including the terms 鈥渂elieves,鈥� 鈥渆stimates,鈥� 鈥渁nticipates,鈥� 鈥渆xpects,鈥� 鈥渟eeks,鈥� 鈥減rojects,鈥� 鈥渇orecasts,鈥� 鈥渋ntends,鈥� 鈥減lans,鈥� 鈥渕ay,鈥� 鈥渨ill鈥� or 鈥渟hould鈥� or, in each case, their negative or other variations or comparable terminology. These forward-looking statements include all matters that are not historical facts, including the discussion in this press release of the Company鈥檚 growth initiative. The forward-looking statements are made pursuant to the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995 and speak only as of the date they are made. Any forward-looking statements that we make herein are not guarantees of future performance and actual results may differ materially from those in such forward-looking statements as a result of various factors. Factors that may impact such forward-looking statements also include the factors discussed under 鈥淩isk Factors鈥� in the Company鈥檚 Annual Report on Form 10-K for the fiscal year ended December 31, 2023 and Quarterly Report on Form 10-Q for the three months ended September 30, 2024; and other factors beyond our control. Should one or more of these risks or uncertainties materialize, or should any of the assumptions prove incorrect, actual results may vary in material respects from those projected in these forward-looking statements. The Company鈥檚 periodic and other filings are accessible on the SEC鈥檚 website at听听. We undertake no obligation to update or revise any forward-looking statements, whether as a result of new information, future events or otherwise.

Healthcare costs traditionally have been a source of major stress for businesses and employees alike, and we鈥檙e seeing that pressure increase. With healthcare costs , employers are grappling to balance costs with fulfilling obligations to employees. Instead of one-size-fits-all solutions, they鈥檙e looking for insights to make smarter decisions about healthcare spending. For healthcare brokers, this shift presents a real opportunity to stand out.

At 成人视频, we鈥檙e seeing a growing focus on compliance, fiduciary responsibility and analytics. Price transparency data is going to be a particularly important area for brokers next year, with a focus on understanding how data analytics and price transparency converge.

But price transparency isn鈥檛 just about checking a compliance box鈥攊t鈥檚 a game-changer for brokers who want to stay ahead. By helping employers make sense of complex data, brokers can uncover opportunities to help their clients identify cost-effective providers, negotiate better direct contracts and optimize their networks.

The Roadblocks to Price Transparency

While at first glance price transparency might seem simple enough鈥攋ust gather the numbers from machine-readable files (MRFs) and share them鈥攂rokers know how complicated it actually is. MRF data includes details like provider names, procedure codes, negotiated rates, allowed amounts for out-of-network services, and plan details.

With MRFs, this information becomes publicly available in a more usable and actionable format, revolutionizing how businesses evaluate pricing strategies, drive reimbursement rates, and gain a competitive edge. But brokers can鈥檛 be expected to sift through billions of machine-readable files (MRFs) and validate these rates on their own. The high volume of data, the variety of sources, the complexity of pricing structures, the need for real-time updates, data privacy concerns, and other issues, collectively turn Transparency in Coverage into a significantly big data challenge.

Third-party tools will play a crucial role in providing solutions as MRF guidelines evolve. While it鈥檚 true your organization can access these files, it is incredibly difficult to turn the available data into actionable insights. You must acquire, clean, and complement the data to make it ready for in-depth analytics.

The reality is that employers need brokers who can bridge the gaps and simplify the complexity.  Without the right tools, brokers are left piecing together answers from incomplete and inconsistent data, an approach that doesn鈥檛 meet modern employers鈥� needs. 

Turning Data Chaos into Actionable Insights

For brokers, tackling the challenges of price transparency means leveraging the latest tools that enable actionable insights, like 成人视频鈥檚 PlanOptix. Integrating big data techniques into healthcare transparency efforts can yield valuable insights for improving patient care, optimizing healthcare processes, and driving informed decision-making.

PlanOptix is designed to compare networks, contract rates and health payors to allow clients to select ideal health plans and networks.
听鈥⑻齀dentifies cost-effective providers, allowing you to create targeted cost-containment programs
听鈥⑻齌ools to benchmark and better understand market position to differentiate
听鈥⑻齈rovides insights empowering clients to negotiate better direct contracts and customize deals to win and retain business

As , 鈥淎ccess to information about the price and quality of health care items, services and providers can help payers build better provider networks, plan designs, and derive more value for their health care spend鈥mployers and other payers have worked in earnest to comply with these requirements, but the results are extremely large data sets and often not suitable for plan sponsor or consumer-facing direct comparison without substantial third-party analysis and have a number of other shortcomings.鈥�

So, while this has traditionally helped payers, this is where tools like PlanOptix now provide real value to brokers. PlanOptix offers brokers a comprehensive look at network performance, highlighting areas where costs can be reduced and benefits improved. It simplifies identifying inefficiencies and helping plans align with client goals.

Rethinking the Broker鈥檚 Role in the Age of Transparency

More than ever, price transparency and smarter use of data are reshaping what it means to be a broker. We often see brokers asking, 鈥淲hat can we do differently for next year?鈥� That鈥檚 when they begin to look at plan performance, review data, analyze trends, and consider options like evaluating new plan designs and implementing point solutions to address employer needs. But employers have moved beyond the once-a-year check-in during open enrollment. They鈥檙e looking for year-round partners鈥攁dvisors who can use price transparency solutions to help them stay ahead.

The message is clear: brokers who adopt tools that provide actionable insights can give their clients the edge they鈥檙e looking for. While both price transparency data and claims data are used in healthcare to understand costs, price transparency data focuses on the listed, negotiated prices for medical services from payors and providers, while claims data reflects the actual costs billed and paid for services rendered to patients, including information on diagnoses, procedures, and payor details based on submitted insurance claims; essentially, price transparency data shows what a service “should” cost, while claims data shows what it “did” cost in a specific patient encounter. Price transparency data has perpetual applications. You can use this data for market research, negotiation positioning, market expansion, pricing new items and services, surfacing it alongside other data, and more. It is detailed down to the payor and provider level, making it a useful tool.

Becoming the Innovative Partner Employers Rely On

The future of healthcare brokerage isn鈥檛 just about crunching numbers or meeting regulatory requirements. Employers are under immense pressure from rising costs, tighter regulations, and growing employee expectations. They need brokers who proactively identify trends, uncover unseen inefficiencies, and don鈥檛 just understand the data but can transform it into strategies that solve problems and deliver results.

This is the critical role brokers play in driving change and innovation. The time to act is now. Brokers who rise to the occasion will strengthen their relationships, grow their business, and shape the future of healthcare鈥攐ne client at a time.