How We Build These Numbers

The source

Under the federal Transparency in Coverage rule, health insurers must publish machine-readable files listing the in-network rates they have negotiated with providers. These files are public. They are also enormous, often tens of gigabytes each, which is why almost no practice ever opens the file that contains its own contract. We download a payer plan file, stream through it, and pull out the negotiated rates for the codes independent practices bill most.

Place of service

We report office place of service, so every number describes the same setting: a service delivered in a physician office. This is not a formality. For the same code, UnitedHealthcare's office rates run about 1.4 times its facility rates, and Cigna's run about 1.2 times. Pooling those two populations produces a figure that describes nobody, and labelling a pooled figure as an office rate would overstate what a facility-based practice collects and understate what an office-based one does.

Note that the two payers do not structure this identically. That 1.4 against 1.2 difference is real, and it means UnitedHealthcare draws a sharper line between office and facility pricing than Cigna does. Read a cross-payer comparison as what each pays in an office, not as evidence that they price the same way.

How we check the numbers

A number pulled from a file this large can be wrong in ways that still look plausible, so we verify every published figure two ways before it goes on the site.

Against the payer's other networks.We extract several networks per payer from separate files and compare them. UnitedHealthcare's networks agree with each other on 98 to 100 percent of code and state combinations. Cigna's agree on 96 to 100 percent. If a cross-check ever falls below 90 percent, our build stops and nothing publishes.

Against the previous month. We re-extracted the same UnitedHealthcare network a month apart. The median ratio between the two months was 1.0000, every one of 250 state and code figures moved less than 5 percent, and 62 percent were identical to three decimal places. Two independent downloads parsed a month apart do not agree that precisely by accident.

That second check also tells you something useful about the numbers themselves: negotiated rates move slowly. A figure on this site does not go stale within weeks. We refresh anyway, but a rate you read today is very likely the rate next month. We would rather state that as an observation across two months than as a promise, because payers renegotiate on their own schedules and a quiet month proves nothing about the next one.

Which files we use, and which we avoid

Insurers publish thousands of files, and most of them are not what you want. Alongside their own networks, they post files for employer plans, rental networks and third-party administrators whose rates can differ wildly from the insurer's real contracts. We use only files the insurer publishes under its own name for a named network, and we sanity-check every extract against Medicare before believing it. A commercial professional rate several times the Medicare amount is almost always a defect in the extract rather than a discovery, and treating it as a discovery is how you publish a number that falls apart in public.

How we aggregate

A single code in a single state has many negotiated rates, because a payer contracts with many provider groups. We report the median, the 25th percentile, and the 75th percentile, plus the observed minimum and maximum, and the count of rates behind each figure. The median is the middle of the market, and the spread between the 25th and 75th percentile tells you how much room the payer has to pay differently for the same work.

The Medicare anchor

Every rate is shown against the Medicare non-facility allowed amount for that code and state. A dollar figure alone is hard to judge. Knowing a payer pays 108 percent of Medicare, or 82 percent, tells you immediately whether the rate is strong or weak for your market.

What these numbers are not

They are not a guarantee of what you will be paid. Your rate depends on your specific contract, your specialty, your group size, and your negotiating power. They are not your contract. They are a benchmark: what the payer pays across the market, so you can tell whether your own rate is competitive or whether it is quietly below where most practices sit. If it is below, that is a conversation worth having with the payer, and one we have on behalf of practices every week.