How a raw insurer file becomes a number you can defend.
Every figure in the product can be traced to a published insurer file and a stated method. This page explains the sources, the steps, the definitions and the checks.
Public data only.
No claims, no patient records. Everything comes from files the federal government or the insurers publish.
Six steps, run every month.
Read the files
Each network's files are downloaded and parsed. Every dollar rate is kept with its code, modifier, billing class and place of service.
Merge identical schedules
Insurers publish the same price list under many network names. Networks with identical rates become one fee schedule, about 315 in total.
Keep networks local
A state or regional network is shown only in the states it serves, so a California plan never appears in an Arizona result.
Link to clinics and clinicians
Each contract is a tax ID with a list of NPIs. The registry gives us the clinic, its location, its clinicians and their specialties.
Keep relevant providers
Insurers attach full fee schedules to every provider. By default we count only specialties that bill the code in Medicare.
Summarise and check
Medians, ranges and the Medicare multiple are computed per insurer, state and specialty, then the quality checks below run before release.
What each number means.
Contract
One clinic's agreement with one insurer: a tax ID and the clinicians billing under it. Rates belong to the contract, not to an individual doctor.
Fee schedule
An insurer's price list. One schedule can be published under several network names; we show it once with the count of networks.
Median per clinician
What a typical doctor is paid. Each contract counts once per clinician, so large groups weigh more. This is the headline figure.
Median per contract
What a typical practice gets. Each contract counts once, so many small practices on a standard schedule pull it down.
Middle 80%
The range from the 10th to the 90th percentile. It shows how much rates spread without being thrown by outliers.
× Medicare
The rate divided by Medicare's amount for the same code, state and setting. 1.30× means 30% above Medicare.
Office and facility
Where the service is performed. Professional rates in a hospital or surgery centre are usually lower, because the facility bills separately.
Global, -26 and -TC
For tests and imaging: the whole service, the professional reading (-26), or the technical part (-TC). The parts are never compared with the global rate.
Every release is checked against Medicare and against itself.
- The -26 and -TC parts add up to the global rate. Median 1.00 across 4,078 lines.
- Facility rates sit below office rates the way Medicare's do.
- Drug codes land close to Medicare ASP.
- Unusual values are compared with the raw insurer file before they are shown.
Median ratio of commercial rates to state Medicare in our test states. Commercial rates are not always higher than Medicare.
When a number needs care, it says so.
Fewer than 50 contracts behind the figure.
The insurer lists more than one rate for the same contract. We show the median and the min–max.
The insurer publishes only the -26 and -TC parts, not a global rate.
The relevant-provider filter is off, so rates for specialties that rarely bill the code are included.
What the data can't tell you.
It is not a quote. Rates are as published by the insurer on the file date shown. Contracts change, and files contain errors.
A listed rate is not proof of service. Insurers list rates for codes a clinic may never bill.
Not every plan type is published. Medicare Advantage and Medicaid managed care fall outside the rule.
Some contracts aren't in dollars. Percentage-of-charges and per-day contracts are kept apart and never mixed into dollar figures.
Capitated care has no fee. Where an insurer pays a group per member, as with Kaiser's own physicians, there is no per-service rate to show.
Patient cost is different. What a patient pays depends on their plan's deductible and coinsurance, which is not in this data.