The evidence
The evidence a rate comparison needs
Start with the agreement and relevant source data. A benchmark gap is a question to investigate—not proof of underpayment or a guaranteed negotiation result.
Contract
Start with the executed fee schedule
Confirm the agreement, rate exhibit and amendments. A payer brand alone does not identify the product, network or rate applicable to your practice.
Compare
Match the service and market context
Match code, year, locality and service setting. National references and hospital prices are not automatically comparable to an independent office’s contract.
Verify
Separate opportunity from actual payments
A modeled gap is not a payer-agreed increase. Check the signed amendment and later allowed amounts before describing an outcome as implemented.
What the public sources can establish
Medicare provides a government reference; transparency files provide published negotiated-rate context. Neither proves what a payer will offer your practice.
- CMS Physician Fee Schedule documentation — match the year, locality and facility/non-facility setting before using Medicare as a comparison.
- CMS Transparency in Coverage guidance — interpret published rates in their plan and provider context, rather than choosing the highest number as a target.
Five comparison factors to check
These factors affect whether a rate comparison is relevant. They are not promises that any specific provision or reimbursement amount can be changed.
- 01
Provider context
Identify the provider type and specialty relevant to the comparison.
- 02
Service type
Code-level weighting differs sharply between contracts.
- 03
Geographic location
Use a relevant locality rather than treating a national rate as local.
- 04
Network status
Confirm which network and participation terms apply.
- 05
Plan type
Keep payer products and government schedules distinct.
Model your own upside
This calculator uses illustrative assumptions, not verified local offers or a forecast of collections. Its range does not establish what a payer will agree to pay.
Estimated annual revenue lift
$177,444 – $561,906
5.9% – 18.7% of your commercial book, recurring every year the improved rates stay in force.
Over three years: $532k – $1.69M
Directional estimate based on typical commercial rate spreads. Your actual range comes from your own fee schedules.
Gated resource · PDF
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