Who publishes machine readable files?
Hospitals and health plans publish different files under separate federal requirements.
| Publisher | File type | What each row contains | Refresh |
|---|---|---|---|
| Hospitals | Standard charges file | A billing code, the gross charge, the cash price, and the rate negotiated with each named payer and plan | Annually at minimum |
| Insurers and applicable self-insured plans | In-network rate file | A billing code, a provider identifier, and the negotiated rate for that provider under that plan | Monthly |
| Insurers and self-insured plans | Out-of-network allowed amount file | Historical amounts the plan allowed for out-of-network claims, by provider and code | Monthly |
Insurer in-network files allow employers to compare negotiated rates across payers for a given provider. Matching the right plan, service and payment terms is essential to that comparison.
Why are the files so hard to use?
The files are public, but their size and structure make them difficult to analyze. Four problems require particular attention.
- File size. An insurer’s release can contain thousands of files and hundreds of gigabytes of data. Processing requires tools that can work through the data without loading an entire release into memory.
- Inconsistent reporting. Publishers can represent provider groups, plan names and code modifiers differently. Analysts need to resolve those differences before comparing rates across files or reporting periods.
- Ghost rates. A listed rate may apply to a service the provider does not perform. A peer-reviewed study of ghost rates documents this problem in Transparency in Coverage data. Those records need to be identified before calculating a usable benchmark.
- Incomplete disclosure. Research on payer file completeness identified gaps that differed across insurers and markets. A separate comparison of four national payers documented differences in disclosure. Check the scope and date of each assessment before applying its findings to a current file.
The research page includes these studies and their methods.
How does a machine readable file become a benchmark?
Producing a benchmark requires a series of processing and validation steps. Each affects the final comparison.
- Ingest. Download the relevant releases, retain their source dates and normalize the file structure.
- Clean. Check for invalid codes, placeholder values and outliers. Use utilization information to help identify provider-service combinations that represent ghost rates.
- Enrich. Add provider affiliations, facility types and geography. Attach quality information where it is available and relevant to the comparison.
- Validate. Compare results with prior releases and relevant claims sources. Investigate whether a rate change reflects a contract change or a reporting difference, and label estimated values.
- Assemble. For episode comparisons, connect the relevant facility and professional services using consistent episode definitions and provider affiliations.
Different analysts can produce different benchmarks from the same files because they make different choices at these stages. Ask how providers were matched, how invalid rates were handled and which services were included.
What can you do with machine readable file data?
The same underlying rates support several types of analysis.
- Employers compare plan payments with other negotiated rates and assess potential changes in purchasing arrangements.
- Advisors and consultants use rate comparisons to evaluate renewal terms, network proposals and provider contracts.
- Payers and TPAs compare their network rates with those reported elsewhere in the market.
- Product teams use negotiated rates in navigation, provider selection and contracting tools.
- Researchers study payment variation and provider markets, subject to the data’s coverage and limitations.
What is inside a Transparency in Coverage file?
The insurer in-network file uses a schema published by CMS. The fields below explain how a rate is connected to a plan, provider and service.
| Field | What it holds | Why it matters |
|---|---|---|
| Reporting entity and plan | The insurer and the specific plan the rates apply to | Identify the specific plan or network before using the rate in a comparison |
| Billing code and type | A CPT, HCPCS, DRG or other code, with its code system | Codes are the unit of pricing; episodes have to be assembled from them |
| Provider group | National Provider Identifiers and tax identifiers for the providers the rate applies to | Ties a rate to a real provider, and to the affiliation data that groups providers into systems |
| Negotiated type | Whether the rate is a negotiated amount, a derived value, a fee schedule, a percentage of charges, or a per diem | Interpret the payment type before treating the value as a dollar amount; some records require additional information |
| Negotiated rate | The dollar amount, or the percentage or multiplier | Read with the payment type, provider and service fields to establish what the value means |
| Billing class and service code | Professional versus institutional, and the place-of-service code | The same procedure code carries different rates in a hospital and an office |
| Expiration date | When the rate stops applying | Separates a live contract from a stale one |
Two features require particular care. First, a reported provider group can include many identifiers, even when only some providers perform a given service. This can create ghost rates. Second, the payment type may describe a percentage or another arrangement that cannot be compared directly with a fixed dollar rate.
Hospital files describe rates from the hospital’s perspective, listing its standard charges and payer-specific negotiated charges. Where hospital and insurer records overlap, comparing them can help identify matching or reporting problems.
How Simple Healthcare helps
We process transparency files to identify ghost rates, flag estimates and retain the source and date of each rate. Analysts access the resulting tables through Landscape, and product teams can use data and licensing. Employers use the rates in Roadmap alongside their own claims. Our published methodology explains the processing choices behind those comparisons.