How Specialty Rate Check is built

Sources

Specialty Rate Check shows commercial Transparency in Coverage rates as a percent of locality-adjusted Medicare. Professional rates use the Physician Fee Schedule. Facility rates use the Medicare ASC fee schedule, wage-adjusted for the practice area.

The ghost-rate filter

A rate is shown only where CMS Medicare utilization shows that NPI billing that code. Unfiltered payer rows never reach a public page. What remains is the set of rates a practice could actually meet.

Professional versus facility rates

A procedure performed in a surgery center generates two payments. The professional fee goes to the physician group for the work of the procedure. The facility fee goes to the ambulatory surgery center for the room, staff, supplies and recovery. Payers publish both, under different NPIs and different billing classes, and Medicare prices them from two different schedules. We show them separately, benchmark each against its own schedule, and add them into an episode total only when both are present.

The two Medicare benchmarks

Professional rates are divided by the Medicare Physician Fee Schedule amount for the same code in the practice's locality. Facility rates are divided by the Medicare ASC fee schedule amount for the same code, with the labor share of the national rate adjusted by the wage index for the ASC's core-based statistical area. A facility rate of 121% therefore means 121% of what Medicare would pay that surgery center, not 121% of the physician fee. The two percentages are not comparable to each other and the page never averages them.

The episode total is the sum of the two dollar amounts. Its percent of Medicare divides that sum by the sum of the two Medicare amounts. Hospital outpatient rates never appear on a practice page.

• An episode total is never shown when either component is missing. The available component is shown with the label “Professional only” or “Facility only”.
• Office visits, imaging read in the office and other codes with no ASC payment indicator have no facility component and are labeled “Professional only” throughout.
• Percentiles are computed separately for each view. A practice's episode percentile ranks its episode figure against peers' episode figures on the codes both have.

How surgery centers are linked

Payer files price facility fees against the ASC's own NPI, so we have to decide which surgery center belongs with which practice. We link in three ways, in this order: a shared tax identification number in the payer file or CMS ownership data; the same authorized official in NPPES; the same street address in NPPES. TIN and authorized-official links are shown as confirmed. Address-only links are shown with a dotted outline and the note “Link unconfirmed” until the practice confirms or removes them when it claims its page. A practice can add any ASC by NPI; we never add a hospital outpatient department to a practice page.

Caveats

• Contracted rate as published by the payer, not what was paid.
• Percentage-of-charge and per-diem rows are excluded. Inpatient is not covered.
• Some payers omit part of their network, and some files lag contract changes by months.
• Hospital OPPS/APC is not in this phase.
• Facility rates depend on a correct facility link.
• ASC wage adjustment uses the ASC's address, not the practice's.
• This is information, not a recommendation.