4 ms·

I would love to hear from an insider on what the difference is between these published files and the internal databases - I'm sure the difference between the tw

I would love to hear from an insider on what the difference is between these published files and the internal databases - I'm sure the difference between the two is striking. Malicious compliance, indeed.

chevman 4y ago
It's really not malicious. What you are seeing here is essentially part of the claims adjudication process output. This takes as input the procedure (ie the ICD/CPT code) and the provider, and runs it against the 'plan design' (which essentially is what includes the provider networks and the associated negotiated rates per procedure) and outputs the resultant cost. Same can be done on the PBM side, just substitute drug for procedure, and 'formulary' for 'plan design'. The interesting question when you look at cross plan, cross provider, and cross carrier variances, is why :) Many companies, careers, and lawsuits, are being born from this data drop. Will be fun times the next decade or so to see how this plays out.
valayal 4y ago
Internal systems are rules engines with hundreds of branches for the most seemingly simple claims. If every payer tried to encode the rules instead of the outcomes of those rules, it would also be entirely unusable, but for a different reason. There is no standard way to encode these contract rules. There aren't any constraints on the legal language that can exist within a contract. When CMS passed this regulation, lots of insurance companies were stuck with systems that flat out could not generate this output. They then had to pay millions to consultants to crunch historical data in order to create these files (which, by the way, is technically not in line with the regulation -- historical data should NOT be used to generate these files). CMS defined in painstaking detail the format and content of these files. Health insurance companies flagged to CMS early on that this would result in a huge amount of data, but at least at the end of it all you get a bunch of dollar amounts, instead of legalese.

chevman 4y ago

It's really not malicious. What you are seeing here is essentially part of the claims adjudication process output. This takes as input the procedure (ie the ICD/CPT code) and the provider, and runs it against the 'plan design' (which essentially is what includes the provider networks and the associated negotiated rates per procedure) and outputs the resultant cost. Same can be done on the PBM side, just substitute drug for procedure, and 'formulary' for 'plan design'. The interesting question when you look at cross plan, cross provider, and cross carrier variances, is why :) Many companies, careers, and lawsuits, are being born from this data drop. Will be fun times the next decade or so to see how this plays out.

valayal 4y ago

Internal systems are rules engines with hundreds of branches for the most seemingly simple claims. If every payer tried to encode the rules instead of the outcomes of those rules, it would also be entirely unusable, but for a different reason. There is no standard way to encode these contract rules. There aren't any constraints on the legal language that can exist within a contract. When CMS passed this regulation, lots of insurance companies were stuck with systems that flat out could not generate this output. They then had to pay millions to consultants to crunch historical data in order to create these files (which, by the way, is technically not in line with the regulation -- historical data should NOT be used to generate these files). CMS defined in painstaking detail the format and content of these files. Health insurance companies flagged to CMS early on that this would result in a huge amount of data, but at least at the end of it all you get a bunch of dollar amounts, instead of legalese.