Aetna, Cigna, United called out for price transparency failures

A new study published in the American Journal of Managed Care found that Aetna, Cigna and UnitedHealthcare continue to lag with healthcare price transparency compliance despite years to update their negotiated rates for the public.

The study conducted by Simple Healthcare evaluated whether the three major U.S. payers reported complete data under the Transparency in Coverage (TiC) rule, which was implemented in 2022 to enable employers and individuals to access pricing.

The TiC rule requires all commercial payers to publicly disclose in-network negotiated rates, out-of-network allowed amounts and prescription drug rates. Payers must also report the prices in a machine-readable format for all providers, updated monthly.

Failure to disclose all required rates could result in enforcement actions, including fines. However, no payer has yet been publicly fined or penalized for noncompliance.

But that doesn't mean payers are fully complying with the extensive price transparency requirements, according to the study. It found that the completeness of pricing data varied significantly across the payers.

For example, Aetna reported, on average, prices for just about half of hospital outpatient codes (51%) and 70% of hospital inpatient codes. For commonly billed codes, Aetna reported an average of 73% of cardiology billing codes, 70% of family practice codes and 86% of orthopedic surgery codes.

Meanwhile, Cigna averaged 20% of common hospital outpatient codes, 81% of hospital inpatient codes, 90% of orthopedic surgery codes and 89% of the most common cardiology and family practice billing codes.

UnitedHealthcare, on average, reported 96% of common codes in cardiology, family practice, and orthopedic surgery, as well as 77% of common hospital outpatient codes. However, the payer only reported 8% of hospital inpatient codes, on average.

Additionally, the study found that Aetna and Cigna generally had network information that was similar to or exceeded their published provider counts. However, UnitedHealthcare had significantly fewer providers in its TiC data than advertised.

Overall, the study deemed Aetna to have "moderate to good completeness" for each of the physician specialties, hospital outpatient and hospital inpatient data. Cigna was considered "good" for completeness for the physician specialties and hospital inpatient data, but it had "very incomplete" hospital outpatient data.

UnitedHealthcare had "very good" completeness for physician specialties and hospital outpatient data, but minimal hospital inpatient data.

The study's findings signal an opportunity to improve healthcare price transparency to ensure federal rules are working as intended, the study's authors stated.

"When insurers report incomplete pricing data, it’s much harder for employers to compare costs and make informed purchasing decisions," David Muhlestein, Ph.D., J.D., founder and CEO of Simple Healthcare and the study’s principal author, said in a statement emailed to RevCycle Management. "Particularly as many plans announce their sharpest rate increases in recent memory, employers deserve access to the complete pricing information they’re legally entitled to."

Incomplete TiC data also limits the abilities of researchers and policymakers to analyze healthcare prices in the interest of market dynamics, evidence-based policymaking and improving health equity, among other priorities.

Recent updates to how payers publish TiC data, though, could help improve compliance. The federal government released a new technical schema to enhance data. Specifically, the updated schema seeks to reduce file size by excluding duplicate data and eliminating unnecessary data fields.

The federal government also plans to release guidance on how payers can make prescription drug pricing publicly available. The information is part of the TiC rule but has not yet been enforced.

Healthcare price transparency is crucial to efficient and functional markets, according to Caroline Pearson, executive director of the Peterson Center on Healthcare, which funded Simple Healthcare's research.

"Employers and consumers need access to complete and accurate pricing data to stimulate competition and make healthcare more affordable," said Pearson.

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.