Your payers' rates are public now. Here's what that means for your practice.
Since mid-2022, health plans have had to publish the rates they negotiate with in-network providers. Most practices have never looked at them. They should.
What changed
The federal Transparency in Coverage rule requires most group health plans and health insurers to post machine-readable files listing the rates they have negotiated with every in-network provider. The in-network rate files became required in July 2022 and are refreshed monthly.
In practical terms, the rate a payer pays the practice across town for a 99214 is now public. So is the rate it pays you.
Why most practices haven't used it
- The files are enormous. A single large payer can publish terabytes of data each month.
- They are organized by plan and network, and identify providers by NPI and tax ID rather than by name.
- Rates come in different forms: flat fees, percentages of charges and bundled arrangements that need to be read carefully.
Turning that into a useful comparison takes a data pipeline, not a spreadsheet.
What the data can tell you
- Where your rates sit against comparable practices for your highest-volume codes.
- Which payers pay you below the market median, and by how much.
- What a gap is worth each year once you multiply it by your volume.
What it can't tell you
Published rates don't show claim volumes, denial rates or how quickly a payer pays. Comparisons also have to be like for like: the same code, the same place of service and the same modifiers. A careful benchmark accounts for all of that before drawing conclusions.
Before your next renewal: pick your ten highest-revenue codes, compare each payer's rate to the market median, and bring the gap to the table in dollars rather than percentages.
If you want to see what this looks like for your own codes, we.ll run a free 2-code snapshot for your practice.