Success Story

Health Plan Going Beyond the No Surprises Act for Price Transparency

Problem: The Challenge of Full Transparency

When the No Surprises Act was passed in 2020, many healthcare companies had just two years to share the costs for more than 500 treatments with their members. The goal of the Act was to increase transparency, so patients would know how much procedures would cost in advance.

However, full transparency is not as simple as it sounds. While members may now be able to go to their health plan’s website to see how much a procedure will cost, there will be many additional fees that they may not be able to find in advance. Take a rotator cuff surgery, for example. Additional charges might include anesthesiologist, pathologist, bloodwork, radiologist, and hospital fees, just to name a few.

Although the Act only requires health plans to share the basic cost for a procedure (not including additional charges), our client wanted to take it a step further. For several years, they had been in the process of building a program that would compile all costs associated with a procedure and share them with members in a way that is meaningful. This would allow clients to enter a phrase, such as “rotator cuff surgery” into the algorithm and come up with an accurate estimate.

The challenge with this type of project is that it involves in-depth data analysis to determine what services (known as procedure codes) go into each and every procedure. And, in order to be meaningful to patients, this needs to be customized for their situation. For example, a 60-year-old female who is going in for a routine wellness exam will have very different procedures than a 25-year-old male.

The client’s challenge was to identify the most common billing scenarios that happen with each specific procedure code and use this data to create meaningful and accurate estimates for its clients. As a company that processes millions of claims per year, this was no small feat. And, with the passing of the No Surprises Act, they needed to speed up their timeframe.

Solution: Price Transparency Solution (PTS)

The client reached out to SourcEdge, and the two companies partnered to conduct the necessary analysis, build the treatment codes, and create the algorithms that would power the online navigation tool. 

Together, they custom built a portal that simplifies costs for members. Members can search by treatment name, procedure code, or keywords to find the necessary information. They can also see physician affiliations, facility prices, and more, including the breakdown of prices for a treatment along with their deductible and copay. Because the company cares about quality, they provide links to outside sources, so members can get additional information about the facilities and practitioners in their region.

Outcome: Value for Members

The client is proud to have created a tool that brings value to their members. They’ve received positive feedback from customers, and their system sees thousands of searches each month.

Due to the complexity of the project, the new portal is built on Cognizant technology, which makes it versatile. The client was recently informed that their old platform would be discontinued, but because of the versatility of the new technology, all of their customizations will be migrated and will continue to work. Had they left their old tool alone, this probably wouldn’t have been the case. By doing what was right for their members, the company itself has also benefitted.

Today, the client is known as a national leader in price transparency, and they have big plans for the future. The number one question driving their decisions is: what’s best for the customer, and what do they need from us right now? Because of this, they have received a number of awards.

SourcEdge’s Role: An Integral Team Member

SourcEdge served as an integral member of the team every step of the way. They conducted analysis, identified what services accompanied various treatments, and developed the analytical components needed to power the portal.

At SourcEdge, we live and breathe in the world of IT for health plans. We serve as a trusted technology solutions provider, staying on top of the regulatory mandates to protect patient information, working closely with world-class software, database, and cloud providers, and focusing on technology solutions that achieve financial and operational returns. Our talented people bring the most modern tools and proven best practices to each project to help health plans serve their members and providers every day.


2024 Cognizant Health Sciences Conference

SourcEdge, An Alivia Company, was Cognizant’s First Healthcare Certified Consulting Partner. During this four-day event, SourcEdge and Alivia Analytics will discuss its combined products and services for commercial and government health plans.