Within the latest ruling in favor of Texas Medical Association, a copy of which you can obtain here, the concept of ghost rates is front and center. What many out of network providers may not understand is just how massive a victory removing ghost rates from QPA calculations really is. In Houston, for code 99283 - ER Level 3 Visit, for Blue Cross Blue Shield removing ghost rates increases the Median In-Network rate from $332.78 to $614.19 (an 84.6% increase!)
How can ghost rates be removed? By using the Taxonomy code system, Transparency in Coverage data (every payer has their own), and a system capable of using the data (OpenCare Data). CMS defines taxonomy as "... a unique 10-character code that designates your classification and specialization. You will use this code when applying for a National Provider Identifier, commonly referred to as an NPI." The example above where $332.78 becomes $614.19 was simply obtained by filtering to only providers with taxonomy code 282N00000X - General Acute Care Hospital listed on their NPI record.
Before applying this filter you will see rates for providers who will simply never perform a level 3 ER (emergency room) visit. These highlighted within the image in the link below are all Ambulatory Surgery Centers who do not possess an Emergency Room yet they have in-network rates for Blue Cross Blue Shield of Texas for code 99283.
BCBSTX In-Network Rates-99283-NoTaxonomyFilter-Houston
After applying the taxonomy 282N00000X filter you are now left with providers who at a minimum are able to perform the procedure.
BCBSTX In-Network Rates-99283-WithTaxonomy-282N00000X-Houston
Further refinement is possible albeit the endeavor becomes more and more difficult. You could remove providers who are closed or who have never performed a procedure. Closed providers is a searchable piece of information however, procedure counts performed by code by provider is not. This procedure performed count could be simply added to the machine readable file format which is already at an NPI and procedure code level. If it does, we will certainly be ready at OpenCare Data to ingest it and make use of it.
Interested in seeing more rate comparisons before and after ghost rates are removed? Let's set up a Zoom and dig in together!