Using Price Transparency Data to Gain a Competitive Edge

The Transparency in Coverage (TiC) rule from CMS requires payers to publish detailed rate data for healthcare services, including those delivered in skilled nursing facilities (SNFs). Until recently, these rates were a closely-guarded secret. With TiC

For SNFs, this is a game-changer. Using Payer Clariti, you can see what commercial, Medicare Advantage, and Medicaid managed care payers are paying your competitors — and what they’re paying you.

Analyzing how rates are set by different geographies, with key operators, or based on quality can guide your payer strategy and inform your market approach.

What Is Transparency in Coverage?

After industry resistance and litigation, TiC rates began to be published July 1, 2022. Starting January 1, 2024, price comparison rates must include information for all covered items and services. Not all payers and plans are compliant with TiC rules.

• The Federal Rule: TiC requires health insurers and group health plans to publish machine-readable files containing their negotiated rates for all covered services
• Scope: Rates disclosed must include both in-network and out-of-network services, including skilled nursing per diem and ancillary charges.
• Frequency: Payers must update these files monthly, keeping information current.
• Access: Every month payers publish over a petabyte (1,000 terabytes) of rate data in machine readable files. The time and cost to find, convert and structure payer data into a usable format is prohibitive for individual providers.

Why this Matters to Nursing Homes and Operators

Transparency in Coverage puts powerful market intelligence in the hands of SNFs for the first time. By harnessing this data, nursing homes can negotiate better rates, make smarter growth decisions, and strengthen their competitive position — all backed by verifiable payer information.

Now you can walk into a contract discussion with hard data:

• See the exact per diem rates your competitors are getting
• Identify payers who undervalue your services.
• Spot opportunities to negotiate rate increases based on market averages.

Understand your Market Position

Rate data can guide competitive analysis and market assessments:

• See if competitors are attracting better rates for the same services.
• Identify the payers that align with your operational and financial goals
• Justify a service line strategy where higher reimbursements validate investment in specialty programs like ventilator care or short-stay rehab
• Evaluate if a payer’s rates in a different county make entry worthwhile

Support Value-Based Discussions

Marry your quality metrics and performance with TiC rates to create a complete picture of your value:

• Show payers how your outcomes justify rate adjustments.
• Demonstrate cost-effectiveness compared to other providers.
• Position yourself as a partner in reducing readmissions and improving patient outcomes.

TiC rate data represents a new opportunity for the post acute care industry to secure effective reimbursement from their Medicare Advantage payers.

Learn More About Managed Care Contracting

Check out these additional Clarity Guides or evaluate your Medicare Advantage rates and contracts with Payer Clariti software.

• Best Practices for Managing Medicare Advantage Cases and Appeals
• A Guide to Medicare Advantage for Post Acute Providers
• Negotiating to Win at Managed Car Contract Negotiations

Stay current with CMS rules and regulations that apply to Medicare Advantage payers and read about the latest news to see what’s coming for managed care in post acute.