How does the price transparency data differ from claims data?
Unlike claims data, the price transparency data comes from providers’ contracted fee schedules. To be as comprehensive as possible, payers often include all the codes included in a provider’s contract even if they may not ever utilize them. For example, a dentist may have orthopedic surgery codes in their fee schedule even though they may never perform a knee surgery. In the price transparency industry, we refer to these as “ghost rates” or “zombie rates.”
To address these “ghost rates” and “zombie rates,” Serif reviews historical claims utilization data at a provider-specific level and at a NUCC taxonomy level to understand what codes different specialties have billed to claims. This is how we generate the column “is_billable” in the data to indicate where we have seen a provider and/or taxonomy actually bill a given code.
For each NPI in the npi_list field, we consider three pieces of information to make the "is_billable" determination: (1) the npi's primary-taxonomy, (2) the npi's secondary-taxonomies and (3) the npi's historical claims records.
You can see examples of an npi's primary and secondary taxonomies here:
The primary taxonomy is 'Critical Access Hospital' and the secondary taxonomies are 'General Acute Care Hospital', 'Skilled Nursing Facility', 'Ambulance', etc...
By default, Signal only returns results using 'balanced filtering' where at least one of the following is confirmed true: primary taxonomy match, secondary taxonomy match, or a confirmed provider claim match in our claims database.
However, you can adjust these filters to be more or less strict by toggling the following on / off inside the filters panel:
- Changing is_billable filter to 'maximum filtering' will filter to only include results where there is a confirmed provider claim in our claims database
- Changing is_billable filter to 'minimum filtering' includes results where an npi's primary taxonomy and/or secondary taxonomy is allowed to bill a code OR we do not have a match in our database (i.e. primary taxonomy or secondary taxonomy are either 'TRUE' or 'UNDEFINED')