This week's issue - multiple unexplained rates per EIN/NPI/CPT/Class 📈

So… if you have Aetna and get a Diagnostic Colonoscopy from Virtual Radiologic Professionals 🏥, your employer will pay one of 1,434 rates listed in the MRF between $16.74 - $1,281. See Attached document. 📄

Highlighting the Issue: ❗ One of the most common issues found in the data is the presence of more rates than can be explained by the data. 😵‍💫 In some cases like radiology, it can be assumed that this is due to the inclusion of rates for global, technical, and professional components, but the data excludes modifiers to separately identify them. 🔍 In other cases, we see a prevalence of multiple rates that cannot be explained and this creates a validity issue for the data:

Only looking at the 70 Shoppable services, the Aetna MRF review had 158,215,326 EIN/NPI/CPT/Class combinations with more than 1 rate 😮

In the raw state, the data is unusable. 🚫

Goal - Can we refine the data down to a single rate per EIN/NPI/CPT/Class/Service Code combination? 🎯

Options for getting to a single rate: 🤔💡 (Grouping by EIN/NPI/CPT/Class/Service Code) 👉Average all the rates 📊 👉Use the Mode Rate 📌 👉Use the Median Rate ➗ 👉Winsorize the top and bottom 1% outliers then average (needs a high volume of rates) 🪄 👉Take the Highest/Max rate 🚀

Recommendation for moving forward: 📣 Take the Highest/Max rate

• All of these options are arbitrary. However, in taking the highest rate, we understand the max a provider will be reimbursed for a service and filter out most of the lower-end noise that likely due to modifiers and other logic not explained by data. 🚀

💡 Ideally, we could have an open conversation with Aetna to learn more about why this is occurring, and they would agree to modify the MRFs to add the required attributes to explain each of the rates. 🤝 Until then, I will be using the highest/max rate approach to simplify these files and filter out millions of rates that cannot be explained. 🗂️

What are your thoughts? 💭 I'm interested to know how you would approach this issue? 🧐

Aetna MRF - 1434 Rates for Same EIN-NPI-CPT.docx

Link to LinkedIn post: https://www.linkedin.com/posts/briandcotter_1434-rates-for-same-einnpicpt-activity-7051889542819115008-prDv?utm_source=share&utm_medium=member_desktop