How to Leverage Payer Data for Better Rates

Until recently, it was impossible for medical practices to confidently negotiate fee increases with payers. Pulse Medical is changing the game.

The Limitation: Accessing Payer Data

In the United States, payers release massive datasets of Machine Readable Files (MRFs) on the first of every month. These MRFs contain detailed information about the rates negotiated with every healthcare provider for every CPTⓇ code and modifier combination across every plan they offer. While this data release was initially implemented to comply with the Transparency in Coverage rules, it has since become a game-changer in healthcare pricing structures. You can find a detailed breakdown of data usage and reimbursement fee negotiation in this article by Gregory Mertz in the Family Practice Management peer-reviewed journal.

Accessing and Using the Reimbursement Rate Data: The Pulse Medical Tool

At HexIQ, we recognize the power of payer data and how it can revolutionize healthcare pricing. We have developed an easy-to-use platform that enables medical practices to download and analyze granular reimbursement rate data within their chosen specialty and geographical region, allowing them to level the playing field with private payers.

Our Pulse Medical team is committed to providing negotiated rate transparency for all at an accessible price point, and we’re doing this by leveraging the massive datasets released by payers every month. By taking advantage of these Machine Readable Files, we’re enabling third parties to shine a light on historically murky pricing structures, promoting transparency, and disrupting the status quo.

We understand the challenges that come with using such massive datasets, and that’s why we’ve developed a comprehensive data processing cycle. Each month, we generate a comprehensive map of providers (by NPI) for every supported payer in the Pulse Medical platform, prioritizing the loading of the most recent data of interest available for our subscribers. From there, we prioritize new requests from current subscribers for any payers they have licensed, and we load negotiated rate data from as many payers as possible to paint and polish more and more of the bridge.

Our platform’s annual subscription is available for $1,000 per payer, and we currently offer data for more than 150 insurance companies, with additional payers added each month based on demand. Our commitment to promoting transparency in healthcare pricing structures and leveling the playing field for all remains steadfast, and we’ll continue to use the power of payer data to achieve this goal.

Pulse Medical is an interactive, easy-to-use, web-based software.

Healthcare providers and researchers can input any procedural codes of choice, select specialties (like family medicine), select any region in the United States, input the 10-digit national provider identifier (NPI) for any provider of interest (not compulsory), and search for respective data. 

It takes only seconds to run and displays the total number of providers, procedures, and the total value in dollars. It also shows the names of practices and their corresponding identification details. You can download the results for rates and providers in an Excel spreadsheet and analyze the data to generate as much insight as you’d like.