A few routine billing concepts that skews line item amounts in raw claim dumps or price lists derived from claim dumps: - CPT modifiers (The service or procedu

A few routine billing concepts that skews line item amounts in raw claim dumps or price lists derived from claim dumps: - CPT modifiers (The service or procedure has both professional and technical components OR More than one provider performed the service or procedure. More than one location was involved OR A service or procedure was increased or reduced in comparison to what the code typically requires etc.,) - Bundling (1 line item as opposed to 2 or 3 when the second and third procedures are an outcome of the first. eg: bone-xray + procedure(s) to fix the broken bone detected through the x-ray) - Rendering provider vs. Billing provider (Rendering provider is the physician or provider that provided the service and billing provider could be the hospital/clinic/lab/ambulatory/billing company etc.,) But here's the kicker. Medicare is the largest payer in the US and it already has a Fee-for-service pricing schedule. You can be sure that it covers all states, locality-wise price adjustments, hospital density factors in the price schedule and every possible procedure billing scenario. So, one just needs to compare (within a ZIP code or County or other geographic area) the hospitals prices against this to find anomalous pricing issues.