Why Price Transparency Data is Non-Negotiable for Your Self-Insured Plan

If your organization self-funds its employee health benefits, you’re not just buying insurance — you’re operating a health plan. That means you bear every dollar of claim cost directly. And if you’re not using price transparency data to manage those costs, you are almost certainly overpaying.

The Opportunity Most Employers Miss

The Transparency in Coverage (TiC) rule, which went into full effect in 2022, requires health insurers to publish machine-readable files containing every negotiated rate between the payer and every in-network provider. For self-insured employers that use an insurance carrier as their TPA (third-party administrator), this means the negotiated rates embedded in your plan are now publicly visible.

Here’s the opportunity: you can now benchmark exactly what your plan pays for any procedure at any hospital against what the same payer pays at competing hospitals across your market.

Three Ways Self-Insured Employers Are Using This Data

1. Rate Adequacy Audits

Many employers discover that their TPA’s “negotiated rates” are not as competitive as promised. Using TiC MRF data, you can pull the rates your plan has contracted for the top 50 procedures your employees use most — then compare them against the market median for the same procedures with the same payer in the same geography.

One SumHealth client, a 2,500-employee manufacturer in the Midwest, found their TPA rates were 23% above market median for orthopedic procedures — their highest-cost service line. Armed with that data, they renegotiated their ASO agreement and saved $1.4 million in the first year.

2. Center of Excellence Network Design

Price transparency data lets you identify which specific hospitals and surgery centers in your region offer the best quality-adjusted pricing for high-cost, high-volume procedures like joint replacements, spine surgery, and cardiac catheterizations.

Rather than paying whatever the TPA network rate is, forward-thinking employers are directing employees to specific centers of excellence with transparent, pre-negotiated bundled payment arrangements.

3. Direct Contracting Leverage

Armed with market rate benchmarks, employers can approach hospitals directly for single case agreements or even direct contracts — bypassing TPA networks entirely for certain services. This is particularly effective for employers with concentrated geographic workforces near major health systems.

What You Need to Get Started

Accessing and analyzing TiC MRF data at scale requires significant technical capability — the raw files are massive and structurally complex. SumHealth’s BenchMarks platform makes this analysis accessible without a data engineering team:

• Search rates by CPT code, DRG, provider, and geography
• Generate instant market benchmark reports for your top procedures
• Export data formatted for TPA negotiations or actuarial review
• Set up alerts when competitor employers’ plans shift market medians

The Cost of Inaction

The average self-insured employer spends $12,000–$18,000 per employee per year on healthcare. For a company with 1,000 employees, that’s up to $18 million annually. A 10% improvement from data-driven contract management — achievable with the right tools and data — is $1.8 million in savings.

The data to achieve those savings is now legally required to be public. The question is whether you’re using it.