New Evidence-Based Healthcare Pricing Standard Available for Paying Out-of-Network Medical Claims

The U.S. healthcare marketplace needs a transparent standard that is fair to patients, providers, and self-insured employers offering health benefits to their employees.

AUSTIN, Texas., April 10, 2024 /PRNewswire/ — In its Healthcare Pricing Guide (HPG) solution, Denniston Data Inc. (DDI) offers standardized benchmark rates by procedure code inclusive of all in-network negotiated rates for every medical service performed by every provider, from every health insurance company. These agreed-on negotiated marketplace rates can be used as the basis for fair compensation for out-of-network providers. 

On Sunday, April 7, 2024, the New York Times ran a front-page investigative article, “Insurers Reap Hidden Fees by Slashing Payments. You May Get the Bill.” This article identified practices used by health insurance carriers and their suppliers to unfairly reduce payments to providers, resulting in additional “percent of savings” charges to self-insured employers and surprise balance billing costs to patients covered under employer health plans. There was no transparent evidence for these disputed charges, and the carriers and their repricing vendor have conflicts of interest in that they receive a percentage of the amount the fees are reduced. The lower the fee cut, the more money they make. According to NYT investigators, last year alone, $23 Billion in medical services fees were eliminated in this fashion, generating $1 Billion in fees to a single repricing vendor.

Out of network medical payments need to be fair to all parties, the provider, payer, and ultimately the patient, so they can get the care they need without creating financial hardship. The evidence for fair prices comes from the marketplace, what providers and payers have agreed to in an arms-length legal contract as a fair price without any conflict of interest.

Healthcare Pricing Guide (HPG) harvests all the prices from the recently mandated Transparency in Coverage files. The Consolidated Appropriations Act, 2021 (CAA) established protections for consumers related to surprise billing and transparency in health care. It created a unique opportunity by establishing the Transparency in Coverage (TiC) and No Surprises Act requirements, making available all negotiated prices from every healthcare payer to every medical provider for every service in the U.S. These rules provided unprecedented access to proprietary price information. However, the datasets are massive and messy, and the value is contingent upon making the data interpretable and actionable.

Because most of the listed prices published by payers are associated with “ghost providers”, providers listed for services they will never perform, DDI uses its own Provider Ranking System (PRS) to filter out these ghost providers to limit the prices on procedures to those actually paid for. Otherwise, there is a risk that benchmark and median rates from TiC data will misrepresent the market, by including false prices that are never paid. Quality control against utilization data allows HPG to set a fair, reasonable standard for reimbursement of out-of-network claims.

DDI is an independent healthcare data organization, with no affiliation with any healthcare insurers or medical care providers. Access to HPG is available as a B2B SaaS for a monthly fee measured by organizational size. There are no fees or royalties to DDI that would represent a conflict of interest or encourage publishing fees higher or lower than market.

About DDI

Launched in 2020, DDI is an innovator in healthcare analytics, lifting the curtain over the US healthcare system. We deliver transparency in physician quality and medical pricing for providers, payers, and member applications using objective, data-driven solutions known as PRS (Provider Ranking System) and HPG (Healthcare Pricing Guide).

More information can be found at www.DennistonData.com.

Contact:
Patricia Whelan 
[email protected]

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SOURCE Denniston Data Inc.