Regulations introduced through the Transparency in Coverage rule require payers to disclose their contracted (‘in-network’) rates with all provider sites in their network, not only for hospitals but also organizations such as physician groups and ambulatory surgical centers. Compliance by payers has been high, but the number and size of the files have created significant challenges for many users seeking to download and understand the data. In the Clarify Health Institute’s latest report titled “Confronting the Zombie Rate Apocalypse: Clarify-ing Payer Rates,” the research team provides insights from their work with payer rate data over the last six months and what’s in store for 2023.

Extracting, cleaning, and enriching 491 terabytes of payer rate data

The initial excitement and curiosity around the release of the payer rates data quickly dissipated as people realized the overwhelming nature of the data. Since July, Clarify Health has downloaded over 491 terabytes of raw, compressed data. Clarify has fully extracted, cleaned, and enriched this data for over 20 national and regional payers through the end of 2022 and will continue to update our data quarterly moving forward.

Once the data is downloaded, Clarify:

• enriches the data with provider and health system characteristics and identifiers;
• identifies plan contracting groups, plan types, and employer affiliations;
• adds service line categories;
• estimates rates as a percentage of Medicare payments;
• and combines the payer rate data with national commercial claims samples to assess utilization.

Clarify-ing payer rate data down to meaningful prices 

And yet, all the data enrichment in the world doesn’t solve the fact that the majority of rates in the data are “zombie rates”: rates that are reported for providers who have never, and would never, provide certain services. To illustrate how overwhelming and complex all this data can be, let’s zoom into one DRG for hip and knee replacements. As shown in the figure below, there are more than 4.5 billion reported payer, plan, and provider rates nationally. For one single DRG! Clarify is parsing publicly available data down to only the most relevant specific rates of interest – the rates that actually matter.

How can Clarify help your organization navigate the zombie rate apocalypse?

At Clarify, we are distilling payer rate information into what people want – insights that allow you to actually understand healthcare costs and compare payer rates for the same service across different facilities. Throughout 2023, Clarify will be hard at work, continuing to process, enrich, and analyze payer rates data. Our roadmap includes the following:

• Completing initial processing of rates data across all national payers.
• Expanding our analysis to all rate types (including bundled, per diem, and percentage-based rates) and service codes (APR-DRGs, CPT, Revenue Centers, and even NDCs).
• Continued releases from the Clarify Health Institute exploring nuances of the pricing of US healthcare services.
• Launching a new version of our Rate Intelligence product, allowing instant insights at the payer, provider, and market levels.

For more information, request a demo or contact the Clarify Health Institute to explore research opportunities and non-commercial use of Rates data.