PayorTransparency

Where do the rates come from?

Payers publish their rates in monthly machine-readable files under the Transparency in Coverage rule. We read each file and compare it with the Medicare fee schedule.

1 written guide

Written guide

See where the rates come from

Step by step

Before you start. The app footer carries the line Rate data is derived from payer machine-readable files published under the Transparency in Coverage rule.

  1. Under the federal Transparency in Coverage rule, health plans publish machine-readable files of their in-network rates. The app reads those files for the payers it tracks.
  2. The app reads payer files each month. The Rate Watch header shows Data through, the month of the files, and Loaded, the day that month reached the app.
  3. For each code, state, payer and month, the app works out a median with a p25 and p75 around it. Each rate counts as often as it is listed in the payer's files.
  4. Rate Watch uses rates filed as dollar amounts. Rates filed as a percent of another schedule are never mixed in.
  5. A payer with no file for a month is left out of that month, never shown as zero. The month before is not copied forward.
  6. The Medicare figure is the fee for the same code and state in the CMS DMEPOS fee schedule, from the latest quarter loaded. On National it is the median of the state fees. The footer under the table on the Rates tab names the quarter.

What you see. The payer pages in the Code Hub on payortransparency.com describe how often each payer posts new files and what becomes of earlier months.

Tip. Under Profile & preferences, the Data caveats tab lists the Standing data limits of how the data is built.

Use case
Where do the rates come from?
Feature
Where the rates come from (Transparency in Coverage files)
Task
See where the rates come from