Medical Student | Engineer | Data Analyst
Medical Student | Engineer | Data Analyst
Transparency in Coverage
The Problem
The Problem
The Problem
Medical practices are forced to accept insurance contracts without any way of knowing if they are being reimbursed fairly. Discussion of reimbursement amongst colleagues and subsequent negotiation action can wander dangerously close to anti-trust law territory with serious legal consequences.
The Need
The Problem
The Problem
With ever increasing expenses, medical practices desperately need a way to determine if their contract negotiation is leaving money on the table. At a throughput of 20 patients/day/provider, a 4 provider practice could be losing out on as much as $100,000/year from bread and butter E&M codes with just a $5 rate deficit.
The New Information
The New Information
The New Information
The Transparency in Coverage (TiC) law enacted in July of 2022 requires health insurance companies to openly publish electronic files containing their entire database of negotiated rates for all in-network providers. This is the first time in the history of modern healthcare that providers have been able to examine the insurance reimbursement of their direct competitors.
The Caveats
The New Information
The New Information
The TiC law is not to the insurance company’s benefit. Intense lobbying pressure has resulted in the admissibility of antiquated and inefficient file formats, complex data structures and *enormous* files well into the hundreds of millions of lines. They are intentionally difficult to work with and payers openly claim that these files are
The TiC law is not to the insurance company’s benefit. Intense lobbying pressure has resulted in the admissibility of antiquated and inefficient file formats, complex data structures and *enormous* files well into the hundreds of millions of lines. They are intentionally difficult to work with and payers openly claim that these files are “not intended for human interpretation” in an attempt to dissuade their usage.
What the data says
"The average regional variation among in-network reimbursement is 80%"
Distributions of negotiated rates are shown as a percent deviance from the median price of a particular CPT and combined by category. The distribution width shows the percentage amount that reimbursement varies amongst providers- a startling 80%.