Price Transparency Data Sample: Top 25 Physician Procedures in Cigna Illinois

**Overview**
Serif Health provides access to comprehensive price transparency data from payor machine readable file (MRF) fee schedules including specific negotiated reimbursement rates by NPI, EIN, specialty, and location for available CPT, DRG, HCPCS, and RC codes. This listing contains a sample for Cigna's rates in Illinois for the top 25 billed CPT procedures. The data includes specific providers' negotiated rates.

**Use cases**

For Providers:
- Competitor benchmarking -- how does your reimbursement schedule compare to peers
- Contracting and payer strategy -- negotiating higher reimbursements with commercial payers
- Roll-ups / acquisitions / M&A -- identifying targets such as highest reimbursed practices in a region
- Provider recruiting and partnerships -- prospecting health systems or individual practitioners to add to your practice
- Margin expansion / improvement -- forecasting revenue impact from changing operations (reducing time per visit from ~45 min. to ~20 min., performing procedures using nurse practitioners vs. physicians, alternative coding, ...)

For Payers:

- Rate and network benchmarking -- size, cost, and scope of networks across competitors and their products (HMO, PPO, ACO, self-insured)
- Network expansion, optimization, and management -- scan market to understand relative cost of care, add providers in-network based on adequacy, create narrow high-performance networks, evaluate provider integration to become a "pay-vider"
- Plan design -- right-size premiums / deductibles based on reimbursement fees, innovate on fee-for-service and create bundles / capitated arrangements

For Employers, TPAs, Brokers

- Network comparison -- comparing cost of care across various networks and products
- Direct contracting -- determining which providers to add to your network
- Payment integrity, claims verification, claims re-pricing -- assess over/under-billing against published fee schedules
- Network tiering and steering -- identify sites with lower cost of care and create dynamic co-pay programs to direct patients

For Pharmaceuticals, Life Sciences, Medical Devices:

- Pricing analysis -- see what 3rd party commercial payers reimburse providers for injectables, medical supplies to capture their margin

**Product details**
Columns included in the sample are:
- Payer: Cigna
- Region: Either IL or "Blank" if not provided
- Network: Localplus PPO
- EIN: A 9 digit taxable identification number without hyphen
- NPI List: Comma separated NPI values
- NPI List Length: Count of NPIs in NPI list
- Taxonomy: Most common NUCC Taxonomy code for the NPIs in the NPI List
- Taxonomy Name: NUCC description associated with NUCC Taxonomy Code in "Taxonomy" field
- Code: 5 character CPT or HCPCS
- Code Type: CPT or HCPCS
- Code Type Version: Year associated with published Code Type
- Modifier List: Any billing code modifiers present on this code and rate, comma separated. If not present, will be an empty string
- Bundled Code List: For ‘bundled’ or ‘capitation’ arrangements, comma separated list of codes included in the bundled rate, otherwise empty string.
- Billing Class: Allowed values: ‘professional’ or ‘institutional’
- Place Of Service List: Comma separated list of CMS place of service codes that apply to the stated rate
- Negotiation Type: Allowed values: "negotiated", "derived", "fee schedule", "percentage", and "per diem"
- Arrangement: Allowed values: ‘ffs’, ‘bundled’, ‘capitation’
- Rate: Decimal with two digits after a period, no commas or dollar signs. e.g. 10125.85
- Additional Information: Any commentary published by payor in MRF, e.g., why 2 different rates exist for the same provider and code
- Is Billable: Allowed values: 'true' if CMS accepts claim from that taxonomy for given code, 'false' if CMS does not accept, 'null" if un-determined
- Matched On: Field explaining data extension source. Allowed values: “Type1NPI”, “Type2NPI”, “TIN”, “ImputedType2NPI”
- Matched ID: The ID (matched or imputed) used to tag this data row
- Entity Name: Organization or Entity Name, from TIN or NPI data sources
- Entity Address: Organization or Entity Address, from TIN or NPI data sources