Price transparency with gaps: assessing the completeness of payer Transparency in Coverage data

Area of Science:

• Health economics
• Healthcare policy
• Health informatics

Background:

• The Transparency in Coverage (TIC) rule mandates payers to disclose negotiated rates.
• Accurate and complete data is crucial for market analysis and patient cost estimation.
• Previous assessments highlighted variability in data quality and completeness.

Purpose of the Study:

• To evaluate the completeness of 2025 Transparency in Coverage (TIC) negotiated-rate files.
• To assess data quality for physician, hospital outpatient, and hospital inpatient service lines across major national payers.

Main Methods:

• A cross-sectional descriptive review of 2025 TIC data releases from Aetna, Cigna, and UnitedHealthcare.
• Data cleaning, parsing, and deduplication were performed.
• Network size and negotiated rate completeness for common billing codes were calculated and compared to marketing materials.

Main Results:

• Aetna and Cigna generally met or exceeded network size claims, while UnitedHealthcare listed fewer providers.
• Negotiated-rate completeness was highest for physician services and lowest for inpatient services.
• Physician and hospital outpatient data were mostly usable, but inpatient data was insufficient for benchmarking.

Conclusions:

• 2025 TIC files are suitable for analyzing physician and hospital outpatient pricing but not for inpatient benchmarking.
• The Centers for Medicare & Medicaid Services (CMS) should audit TIC file completeness and enforce penalties for non-compliance.