The payers are mandated by the Transparency in Coverage Rule to publish every rate they’ve negotiated for every NPI for every code in every service setting every month. This translates into an enormous amount of data. Pulse Medical distills this data into manageable chunks that you can use to answer your specific business question.

Question: Okay, but there’s still a lot of information to take in here. What exactly am I looking at?

Let’s walk through a simple example together.

Dr. Amy Bessnow is a Hematology & Oncology specialist based in New Hampshire. 

Let’s do a search for her negotiated rates for a 30 minute appointment with an established patient (CPTⓇ code 99214) in an office setting (place of service 11).

Here’s the resulting spreadsheet:

We can see that Dr. Bessnow has two unique rates listed in Column K in 8 rows, ranging from $161.03 to $444.30.

Question: But, why are there so many rates listed?

Each rate for Dr. Bessnow rolls up to a different Tax Identification Number (or tin), which is the business entity that owns the published rate with the payer (in this case Anthem Blue Cross Blue Shield of New Hampshire).

When Anthem receives a reimbursement request with Dr. Bessnow’s NPI (1083766786) for this service (99214) in this setting (11, office), the rate they will reimburse the provider depends on which Tax ID Number (TIN) is making the request.

Apollo Medical Group of Wentworth PLLC can bill $161.03 for this office visit, and Dana-Farber Cancer Institute, Inc. can bill $444.30 for this office visit.

So, if you’re trying to answer the question, “What is Dr. Bessnow’s negotiated rate for office visit 99214 in place of service 11,” you’ll have to factor in which parent organization her services are being billed under.

You can additionally run the same report to include different places of service.

For example, Dr. Bessnow has different rates for office with some parent TINs  (POS code 11), in-patient hospital (POS code 19), skilled nursing facility (POS code 31), and hospice (POS code 34).

So, if you’re trying to answer the question, “What is Dr. Bessnow’s negotiated rate for office visit 99214,” you’ll have to factor in which place of service code 99214 is being billed under.

Pulse also allows us to search for rates by the parent Tax Identification Number that owns the rate. If we wanted to dig deeper into the rates for a specific practice like New Hampshire Oncology-Hematology PA (TIN 1467485870), we can see this following information:

Column K shows a range of rates from $238.54 to $444.30 for 12 different providers:

So, if you’re trying to answer the question, “What is the negotiated rate for New Hampshire Oncology-Hematology PA for office visit 99214 in place of service 11,” you’ll have to factor in which child NPI the services are being billed for.