Healthcare Price Transparency: Can Policy Meet Practicality?

By Vanessa Candelora, PP&T  Management & Operations Lead

Efforts to achieve meaningful price and cost transparency in healthcare have been underway for years, driven by the idea that informed consumers, employer groups, and patients could help lower overall healthcare spending. One goal has been to give patients access to the prices of treatments and services in advance, allowing them to compare options, factor in quality and make cost-conscious decisions about their care with specific cost estimates for planned services.

Yet despite increasing focus, real change remains elusive. Patients still struggle to access clear, actionable price and cost information, and the shift toward consumer empowerment has been slower than hoped. Historically, payers and providers have negotiated prices behind closed doors, leaving consumers in the dark. Recent regulatory activity has begun to challenge that dynamic, creating disruption. Some leaders in the industry recognize that with disruption comes the opportunity to reimagine how pricing information can be shared and used more effectively across the healthcare system.

Before we dig into the current landscape, let’s take a quick look at the history of federal healthcare cost transparency efforts. Cost transparency is one of the few healthcare issues that has consistently drawn bipartisan support, with efforts advancing under both Republican and Democratic administrations. Here are some policy highlights.

The 2010 Affordable Care Act marked a shift toward greater awareness of healthcare costs, requiring payers to disclose plan information on the federal health insurance marketplace. In the years that followed, federal rulemaking advanced price transparency by mandating that hospitals publicly share their chargemaster data, which is a detailed list of billable services and items provided to patients.

In June 2019, Executive Order 13877, Improving Price and Quality Transparency in American Healthcare to Put Patients First, called on hospitals and health plans to increase transparency. This led to the Hospital Price Transparency Rule requiring hospitals to publish standard charge information, including negotiated rates, in machine-readable files (MRFs) and offer a consumer-friendly display of at least 300 “shoppable” services.

In October 2020, the Transparency in Coverage rule added a similar requirement for health plans to publish MRFs with negotiated rates and provide an online shopping tool to help consumers estimate out-of-pocket costs.

In December 2020, the No Surprises Act (NSA) was enacted as part of the Consolidated Appropriations Act. It aims to protect patients from unexpected medical bills by prohibiting surprise billing in certain scenarios and requiring providers and payers to furnish good faith estimates (GFEs) before services are delivered.

These federal efforts layer onto a growing and varied patchwork of state-level regulations aimed at increasing data and price transparency. Most recently, the Centers for Medicare and Medicaid Services (CMS) issued a Request for Information (RFI) asking for input on price transparency—what’s lacking, which workflows need it most, and what could drive better solutions. Topics covered in RFIs often signal upcoming rulemaking or other policy action.

Despite more than 15 years of effort, payers and providers continue to struggle with meaningful compliance, low patient usage of limited shopping tools, and unclear or inconsistent regulatory enforcement. If the goal of price transparency is to empower patients and reduce overall healthcare costs, the results so far have been underwhelming.

So, where are we now? The 2025 Executive Order on price transparency has renewed urgency with stronger mandates and a new round of federal attention. The order, titled “Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information,” directs the Departments of Treasury, Health and Human Services (HHS) and Labor (commonly referred to as “The Tri-Agencies”) to:

• Require disclosure of actual prices for healthcare items and services.
• Standardize how pricing information is presented for easier comparisons across payers and hospitals.
• Strengthen compliance of current policies to ensure reporting of complete, accurate, and meaningful data.

This article will explore why transparency still matters, what is really happening in the industry, and what it will take to move these complex compliance requirements to effective solutions that truly meet the vision of reduced costs and improved healthcare with patients at the center.

Why Transparency Matters More Than Ever

The urgency to improve price transparency is not solely driven by legislation or executive orders. Rising healthcare premiums and the growth of high-deductible health plans have placed significantly more financial responsibility on patients. According to the KFF 2024 Employer Health Benefits Survey, the average annual deductible is now 47% higher than it was a decade ago. Although both employers and patients often shoulder substantial costs, they remain largely excluded from direct pricing negotiations involving hospitals, insurers, and providers. As a result, patients are often unable to access real, negotiated prices and their expected out-of-pocket costs before receiving care, limiting their ability to plan financially or make informed decisions.

The lack of reliable pricing data continues to have real financial consequences. A KFF/National Public Radio poll found that 41% of American adults currently carry some form of medical or dental debt. Many of these individuals were unaware of the costs they would face until after receiving care. Without access to negotiated rates or realistic cost estimates, patients have little ability to budget for services or avoid unexpected bills—undermining the very intent of price transparency initiatives.

Clinicians also face challenges. Many lack access to reliable, patient-specific cost information at the point of care. Although the adoption of real-time pharmacy benefit check (RTPB) is improving transparency for medications, patients asking about service costs are often referred to hospital billing departments or health plan administrators. In some cases, they may be pointed to online cost transparency tools, which, if used correctly, might provide a range of estimated costs. Still, significant barriers remain. It is perhaps not surprising that 41% of insured Americans have avoided medical care for fear that their coverage would not meet the costs. Reliable cost transparency helps clinicians and patients navigate these decisions more effectively. It can support upfront conversations, facilitate better treatment planning, and improve hospital revenue cycle management by reducing surprise bills and enabling point-of-service collections.

Despite these benefits, true transparency remains elusive. In 2023, more than 679,000 federal independent dispute resolution actions were initiated—97% related to out-of-network emergency or nonemergency services. This volume far exceeded the government’s original estimate of 22,000 disputes and reflects ongoing misalignment between payers and providers, with patients often caught in the middle.

Mandated MRFs from the Hospital Price Transparency and Transparency in Coverage rules were intended to improve visibility into prices and negotiated rates. In practice, these files present a number of challenges. While they contain extensive data, they often lack standardized formatting and identifiers, making it difficult to process and interpret. A blog from health tech vendor Merative noted that some files list multiple rates for the same service at the same location by the same provider, while others include ambiguous identifiers such as multiple National Provider Identifiers (NPIs) or tax identification numbers. Variability in how health plans structure rates, such as fee-for-service versus bundled payments, adds another layer of complexity. Discrepancies and inconsistencies across tools erode trust and contribute to care avoidance.

These systemic challenges are a key reason the White House called for increased enforcement in the January 2025 executive order on transparency. For transparency efforts to be effective, they must move beyond compliance checkboxes and instead focus on rebuilding patient confidence. That means delivering clear, consistent, and actionable cost information that supports better decision making and more proactive engagement with care.

The Future Vision: Patients as Savvy Healthcare Shoppers

What does it mean to live in a world where patients are part of the healthcare cost equation in a real way?

While most patients aren’t used to shopping for care the way they would for flights, cars, or a can of peas, the desire to research and make informed decisions for their health care coverage and services is not new. Searching for a provider in their area that speaks their language and provides the service they need covered in-network is well understood to be available data. Initiatives addressing data quality in directories that are often littered with inaccuracy is a good step forward, and the No Surprises Act brings accountability for in-/out-of-network information. Patients have also grown more comfortable evaluating healthcare quality. Many are familiar with using Star Ratings and browsing provider reviews on sites like Zocdoc or Healthgrades to compare the quality and patient satisfaction of physicians and facilities.

The reality is that most patients are still navigating a system where there is friction at every turn because tools are fragmented, cost estimates are inconsistent, and few platforms provide the context patients need to make informed choices. If transparency is going to be meaningful, the starting point must be the patient experience.

To empower patients as informed healthcare consumers, the industry would need to develop tools offering real-time, personalized cost estimates integrated into digital platforms that patients will use. These tools should provide accurate, comprehensive information, including provider directory information, quality ratings, and patient-specific out-of-pocket cost estimates with progress made toward deductibles, copay information, applicable requirements such as prior authorization, and clear definitions of bundled services.

Enabling patients to make decisions easily and effectively plan their financial responsibility is good for health plans and providers too, and not just for compliance and reduced risk of legal action. Here are some benefits by non-patient stakeholders:

• Health plans: With increased cost transparency capabilities, payers will have stronger trust relationships and loyalty with their members, employer groups, and provider networks. In addition to an elevated ethical reputation, higher member satisfaction and retention, payers can leverage successful consumer-friendly transparency tools as a competitive advantage (e.g., promote innovative cost-saving programs, highlight access to a high-quality provider). Payers would also have a reduction in unnecessary spending by encouraging patients to choose more cost-effective options.
• Hospitals and providers: Providers will also have stronger trust relationships with patients when transparency opens communication for more collaborative care and thus better outcomes. Competition encourages innovation to offer higher value and lower-cost care. Providers have more data to leverage in negotiations, offer discount programs, and provide confidence in patients’ decision making with a holistic picture of care, with cost as one factor. When the cost of services is known beforehand, patients are empowered to plan their finances and pay medical bills more efficiently, improving revenue cycle management.  

Achieving this vision requires:

• Interoperability and standards: seamless, timely standard data exchange between payers, providers, and consumer-facing platforms.

• Patient-friendly transformation: clear definitions for common procedures, streamlining processes, and simplified, improved tools that patients will use.

• Regulatory alignment: harmonization of efforts to create cohesive and enforceable data standards to support automation and reduce burden.

Ultimately, transforming patients into proactive healthcare shoppers can be a win-win-win but necessitates a collaborative approach, integrating technological advancements, process improvements, and policy reforms to create a transparent and patient-centric healthcare ecosystem.

Burden or Breakthrough: Impacts on Payers and Providers

What will it take to empower patients, repair trust, and improve the health and lives of patients who want to make cost-informed decisions?

Well, it’s complicated. Behind this vision lies a sobering reality: most payers and providers are still wrestling with manual processes, ill-equipped standards, and unclear expectations that lack enforcement across all three policies. Many are left wondering how they can possibly invest any more into tools they fear won’t be used when there are other mandates, interoperability standards, and market-driven innovation opportunities on their roadmap. Others may have useful online shopping tools today and checked the box on MRFs but are just at the surface of the Good Faith Estimates and Advanced Explanation of Benefits (AEOBs) requirements required by the No Surprises Act.

The NSA is groundbreaking with the ability to transform how patients make decisions about their care, but is highly contrary to how providers and payers operate today. The burden of the act has been heard throughout the industry since 2020. It requires GFEs and AEOBs, but without automation and aligned standards, the risk of increased administrative burden is steep. Some large hospital systems estimate they’d need to hire dozens—even over a hundred—of new staff to manually produce GFEs to comply with the NSA. Moreover, with interoperability still a work in progress, coordinating with payers to produce AEOBs remains far off territory for many hospital systems.  

For payers, the back-end complexity is immense. Most plans have copied and stripped down their adjudication systems for generating patient estimates. A few health plans are exploring how to repurpose existing claims standards, specifically the X12 837 format, despite its known limitations for NSA compliance. Efforts to “rig” a solution using existing X12 remain more of a partial workaround than true progress, and NSA compliance continues to sit in a regulatory and industry standoff while standards work to support the industry in the best way possible. Legislators seek enforcement. Regulators seek enforceable standard solutions. The industry, citing feasibility concerns, is asking for flexibility and slower requirements.

What does a breakthrough look like?

Interoperability standards: Around the same time, the Health Level 7® International (HL7®) Da Vinci Project had already begun public convenings for Patient Cost Transparency (PCT) to define an open-source data standard leveraging modern web technologies using Fast Healthcare Interoperability Resources (FHIR) application programming interfaces to streamline and automate. PCT defines a workflow that meets the end-to-end requirements of the No Surprises Act GFEs and AEOBs, but requires transformational thinking with how some payers and providers operate today. Also, while implementing PCT would piggyback on the investment payers and providers are making for the CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-P), including recommended CARIN and Da Vinci work, this is new for many organizations, especially those still using fax machines.

X12 also began work on the development of the Health Care Good Faith Estimate X370 transaction standard as a use case̶ level implementation guide specifically supporting the GFE requirements of the NSA from provider to payer.

While initiatives are underway, coordination and collaboration among these efforts is essential to meet the industry where it is while also preparing for the future.

As established, the regulation exists, but enforcement has been underwhelming. With uncertainty in the role of government in general, it’s an opportunity for the industry to take charge, collaborate, and develop solutions to solve these problems together. The business case is tricky and it’s essential to fit this work into existing efforts, leveraging systems that are in place today. We must find the balance of advancing interoperability and transparency in meaningful ways without too much burden/reinventing the wheel.

Transparency of prices and healthcare costs across all financially responsible parties, including payers, providers, and consumers, reduces the friction across all parties by enabling more comprehensive negotiations, less financial stress, and healthier patients.

Beyond the Data: People, Process, and Standards

As we’ve outlined throughout this article, progress on price transparency has been more fragmented than transformative. While regulatory mandates and policy pressure are essential drivers, they aren’t enough for organizations to make meaningful progress. Getting this right isn’t just about posting data. It’s about how organizations manage, share, and act on those data internally and across the healthcare system, leveraging their unique assets to improve health and reduce the cost of care.

To accommodate GFEs, for example, providers and payers may need to implement operational and system changes to data exchange, internal processing, and contracting, and implement staff training across a wide swath of business units. That’s where business processes, organizational readiness, and strategy must take over.

Payers can take real steps now, starting with their own data. Aggregating historical claims can help uncover cost variability and surface inconsistencies that impact member-facing estimates. Setting up simplified adjudication of GFEs to test and improve accuracy for NSA compliance and working with partners to consider the best delivery of advanced explanation of benefits for actionable and improved patient experience is key. As we look at the broad interoperability strategy, reducing silos of data for alignment across tools for better contracting, member experience and reduced friction will separate leaders from the laggards.

Vendors have a critical role to play in bridging the usability gap for patients, coordinating for one cohesive good-faith estimate for services involving multiple providers, and data aggregation for analytical insights. They can help operationalize standards, align formats and build interfaces that translate raw pricing data into consumer-friendly experiences, but they need clear direction, thoughtful integration strategies and leadership from those delivering care.

Ultimately, the biggest bottleneck isn’t just technology. It’s people, processes, and priorities. Data transparency is a systemwide transformation, and systems don’t change without alignment, investment, and a thoughtful plan.

Final Thoughts: From Mandate to Meaningful Change

The policies are here. The standards are in development. The pressure continues to mount. But the real question remains: will transparency stop at compliance or become something more?

Achieving meaningful transparency requires more than checking regulatory boxes or publishing machine-readable files. It requires consistent enforcement and accurate, accessible, and timely cost information that is understood by the people they’re intending to help. Transparency efforts that fail to consider the patient's experience will risk becoming yet another high-cost compliance exercise that benefits no one.

Patients already struggle to interact with the healthcare system. From confusing bills to fragmented portals, every step introduces friction. If transparency becomes just another layer of complexity, we’ve missed the point entirely. We must ask ourselves: how can we meet patients where they are? How do we deliver information in a way that builds understanding, not frustration? How do we build upon all the work we’ve done to innovate without breaking the bank?

Involving patients in the planning and design of transparency initiatives is not just nice to have; it’s essential. Whether through user testing, human-centered design principles, or collaboration with patient advocacy groups, we need to ground our solutions in real-world usability. Education is key. Without context or guidance, even the most accurate cost estimate may be misinterpreted or ignored. Transparency done right should reduce stress in patients, strengthening relationships and value across payers, providers, and consumers, all while lowering the cost of healthcare.

To truly move from mandate to meaningful change, organizations must shift their perspective. Transparency is not just a compliance obligation, it is a business strategy, a patient engagement tool,, and a competitive differentiator. Those who embrace it in that spirit will not only meet requirements but also build trust, streamline operations, and contribute to a more navigable and equitable healthcare system, reducing costs in the process.

The future is transparent, patient-first healthcare,, and that includes cost information in advance of services. If organizations aren’t thinking strategically about their interoperability strategy and how price and cost transparency will impact you or your clients, we hope you reach out!

If your organization needs assistance in better understanding the overlapping policies and what is required by you or your clients, investment prioritization/roadmap validation, or interoperability strategy and planning, we can help. Maybe you need a go-to-market strategy or simply just a sounding board. Either way, reach out to set up some time to talk. Let’s examine your challenges and explore how we might support your goals. Sometimes, just voicing a problem brings the clarity you need to move forward. We're ready when you are.