We provide up-to-date health plan negotiated rates and allowed amounts in easy-to-use data models by Payer, State, Service, and more.
Joined April 2023
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True story: we recently reviewed an external analysis comparing emergency visit reimbursement between two competing health systems. The conclusion?
Hospital A receives 1.5x more than Hospital B.... which, in fact, turned out to be wrong.
Not only wrong, but when we looked at the complete picture, Hospital B was actually being reimbursed higher.
How did this happen? 🧵
There's another layer worth understanding: percent-of-charge contracts.
Many large systems tie reimbursement to what they bill, not a fixed fee. That means they can raise effective reimbursement just by updating their chargemaster, with no renegotiation required.
Both sides have reasonable logic here. It comes down to how each party wants to manage risk and exposure.
Most real contracts are hybrids: percent-of-charge for high-acuity, fee schedules for routine outpatient work, case rates for inpatient, carve-outs for implants and high-cost drugs.
Without actual remittance data, these arrangements stay opaque. MRF estimates alone won't cut it.
Price transparency data works, but only when you use the right methodology, the right data sources, and understand how hospital contracting actually functions.
A surface-level analysis does not just fall short. It points you in the wrong direction entirely.
We are still early in this industry. The work is worth doing right.
Full breakdown: payerset.com/post/a-practica…
A stronger approach: model the full visit bundle and cross-reference three data sources.
Payer transparency files
Hospital self-reported data (MRF-attested as of July 1, 2024)
Actual claims data (835 remittance)
When applied correctly to the same two hospitals, the conclusion flipped entirely.
Hospital B came out roughly $100 ahead on the full bundle, about 10% higher overall, mostly through higher lab reimbursement the original analysis never saw.
Price transparency data is one of the most powerful tools available to managed care teams and healthcare consultants right now.
It is also one of the most commonly misunderstood.
We've pulled together a framework of best practices we've learned from our customers. 🧵
We will be walking through exactly this framework applied to a real Level 4 emergency visit comparison in our next post.
Two hospitals. Same market. Same payer. Very different story depending on whether you look at one code or the full picture.
If you want to read more, check out the full guide here: payerset.com/post/how-to-ana…
We had the opportunity, along with a few other leaders in the price transparency community, to sit down with @CMSGov and @HHSGov to give candid feedback on the state of price transparency and recommendations for further accelerating the mission.
One of the main themes - continuing to accelerate timelines with incremental changes vs. waiting for "everything" to be done.
What a great session meeting with @CMSGov & @HHSGov leaders talking about price transparency progress and improvements.
Lots of good stuff happening payerset.com/post/cms-propos…
Payerset retweeted
Real prices will forever transform the American healthcare system. Price transparency unleashes competition and shifts the power to the true purchasers of care — patients, employers, and taxpayers — allowing them to lower their costs and be protected from overcharges.
NEW: Trump used an executive order to direct three federal agencies to enforce the health care price transparency regulations he rolled out during his first term. trib.al/0sLWNRm
✨ Celebrating a Year of Impact at Payerset ✨
2024 was an incredible year as we’ve been privileged to work alongside healthcare leaders and innovators who share our vision for a more transparent and equitable system.
Read more about our recap of 2024 and our vision for 2025 and beyond in this article from our co-founder, Jerry Dimaso: payerset.com/post/2024-refle…
#PriceTransparency #HealthcareInnovation #Payerset #Healthcare
Lots of exciting things are coming in 2025, but in case you missed it, check out one of our favorite podcast episodes with Andrew Gordon!
When a few companies control the market, competition takes a hit, opportunities shrink, and innovation slows down. It’s not just a business challenge, it’s a consumer issue too.
🎙️ Take a listen to the full episode as Andrew breaks down the need for healthcare price transparency on the Payercast podcast: payerset.com/post/exploring-…
#Payerset #Payercast #PriceTransparency #Healthcare #HealthcareInnovation
Employers are taking charge of healthcare. 💼💡 With price transparency data, they’re skipping insurers & building direct-to-provider care models. A game changer? Andrew Gordon dives into this on the latest #Payercast. Listen now: payerset.com/post/exploring-…
#PriceTransparency #HealthcareInnovation #Payerset
What do you think, Payerset community? Is "playing chicken" with our healthcare truly the only option hospitals have to increase reimbursement rates with insurance carriers?
thirdway.org/report/stop-hos…
The recent Third Way report on patient dumping sheds light on a troubling issue, but is it somewhat one-sided?
When negotiations turn sour, don’t insurance carriers play a role too? Either way, patients are caught in the middle, bearing the brunt of the fallout.
