The Centers for Medicare and Medicaid Services (CMS) is responsible for issuing new regulations requiring that require health plans (e.g., health insurance companies and third party administrators) to publish negotiated healthcare prices and out-of-network prices to a public website in machine-readable formats.
At Keywell.ai, we can help you analyze healthcare price information with our data repository with over 100 Billion reported prices from payers including UnitedHealthcare and Blue Cross Blue Shield, the nations largest health insurance carriers.
For example, the map below shows rates reported for the Austin, TX and Round Rock, TX core-based statistical area for an abdominal CT scan with contract (HCPCS code 74177). Each payer reported these rates in machine-readable files. The data was processed through the Keywell price transparency data processing engine and mapped to geographic physician locations.
Unlike recent hospital price transparency laws (which were largely not enforceable due to low penalties), the payer price transparency rule has resulted in widespread data availability. Substantially all negotiated rates between payers and providers is included in the data.
The health plan price transparency data includes rates by procedure code negotiated with providers. Providers are identified through a tax identification number as well as all the associated national provider identifiers associated with the particular rate. Rates are also designated by specific arrangement types, service code, and procedure code modifiers. More details on the reporting requirements and data specifications can be found on the CMS TRANSPARENCY IN COVERAGE WEBSITE.
The data reported by payers is complex and significant in size. Some payers are reporting more than one rate for an individual NPI without differentiation of the type of service or other billing code modifiers. We’ve developed and validated algorithms that identify and score the rates with the highest likelihood of accuracy to clear the noise.