This is a redacted copy of a client deliverable. Client, entity, department and geographic names, the home-state Blue plan’s network product names, and regional payer names are replaced with neutral codes (Market A/B/C, Group A1…, Plan B1…). All figures are unmodified.
Twelve months of adjudicated charges across three markets, priced payer by payer against Medicare, with the worklists for its $23.83M of open AR.
The Medicare benchmark here is the client’s own Medicare FFS remits in each market, not a published fee schedule, so it already carries that locality’s geographic adjustment and the 2% sequestration reduction. Negotiated contracts ranked by annual dollars below Medicare, with the code-level detail on click. Codes where a payer pays above Medicare are not netted against the gap: the total is the sum of the shortfalls only. Because physician and NP/PA claims are priced separately, a code can sit above Medicare on the blend and still carry a gap where the NP/PA rate is short.
| Payer | Market | % of Medicare | 12mo volume, top 18 codes | Annual gap | Largest single code |
|---|---|---|---|---|---|
| + BCBS | Market A | 89% | 107,584 | $998,106 | 99214 · $554K/yr |
| + UnitedHealthcare | Market A | 96% | 35,093 | $205,662 | 99214 · $94K/yr |
| + Medicare Advantage | Market A | 112% | 144,842 | $94,002 | 87428 · $40K/yr |
| + Cigna | Market A | 89% | 11,550 | $91,538 | 99214 · $48K/yr |
| + Aetna | Market A | 88% | 7,381 | $63,061 | 99214 · $40K/yr |
| + BCBS | Market C | 100% | 12,888 | $48,617 | 99213 · $15K/yr |
| + Aetna | Market C | 76% | 1,353 | $23,085 | 99213 · $10K/yr |
| + Plan B2 | Market B | 131% | 6,139 | $12,956 | 87428 · $9K/yr |
| + UnitedHealthcare | Market C | 88% | 1,290 | $12,089 | 99213 · $4K/yr |
| + Cigna | Market C | 82% | 826 | $12,009 | 99214 · $4K/yr |
| + Medicare Advantage | Market B | 116% | 8,755 | $8,126 | 99203 · $3K/yr |
| + UnitedHealthcare | Market B | 137% | 4,068 | $7,866 | 87428 · $4K/yr |
| + BCBS | Market B | 125% | 12,336 | $6,333 | 87428 · $3K/yr |
| + Plan C1 | Market C | 93% | 1,085 | $5,163 | 99214 · $2K/yr |
| + Plan B1 | Market B | 138% | 4,761 | $4,840 | 36415 · $3K/yr |
| + Aetna | Market B | 105% | 1,404 | $3,728 | 99213 · $3K/yr |
| + Cigna | Market B | 113% | 2,600 | $3,722 | 99213 · $2K/yr |
| + Medicare Advantage | Market C | 98% | 3,442 | $2,114 | 87637 · $1K/yr |
Visit codes are matched on rendering provider type († in the detail); on those rows both dollar figures are the provider-type-weighted blend, so the Medicare figure will not match the all-clinician median shown in section 05. Government and program payers (Medicaid, TRICARE/VA, workers’ comp) are excluded, since their rates are set by program rather than negotiated. Scope is the top 18 codes by volume in each market.
Federal price-transparency rules require BCBS-A to publish the rate it has negotiated with every contracted provider. Its file, matched to the client’s five Market A tax IDs:
| Plan | Code | BCBS publishes | BCBS pays | % of published | Billed 12mo | Difference per year |
|---|---|---|---|---|---|---|
| BCBS-A (PPO)* | 99214 | $87.86 | $78.22 | 89% | 19,793 | $190,805 |
| BCBS-A (PPO)* | 99213 | $56.90 | $48.11 | 85% | 10,876 | $95,600 |
| BCBS-A: Blue Network 2 (PPO) | 99214 | $81.80 | $68.55 | 84% | 5,937 | $78,665 |
| BCBS-A: Blue Network 2 (PPO) | 99213 | $52.97 | $38.42 | 73% | 3,400 | $49,470 |
| BCBS-A - Network 1 (PPO) | 99214 | $87.86 | $80.49 | 92% | 1,490 | $10,981 |
| BCBS-A - Network 1 (PPO) | 99213 | $56.90 | $50.13 | 88% | 823 | $5,572 |
* BCBS-A (PPO) is the largest plan by volume but that plan name does not appear in the file. BCBS-A’s commercial PPO business runs on Networks 1 and 2, so the Network 1 schedule is assumed for it; the $144,688 on the two plans matched by name is the figure that does not rest on that assumption.
Median allowed for 99214 by half-year. The step down appears inside each plan product separately, so it is a rate change rather than a shift in which plans the client’s patients carry. The client’s own employee plan, new in 2026 and administered by the same BCBS-A, pays $90.49 for the same visit: 20% above the main PPO’s $75.49, and more than any commercial product in the table.
| Plan product | 2024H2 | 2025H1 | 2025H2 | 2026H1 | 2yr change | Charges 2026H1 |
|---|---|---|---|---|---|---|
| BCBS-A (PPO) | $88.22 | $85.06 | $80.49 | $75.49 | −$12.73 | 7,935 |
| BCBS-A: BLUE NETWORK 2 (PPO) | $85.06 | $85.06 | $75.06 | $68.55 | −$16.51 | 2,527 |
| BCBS-A | $93.22 | $88.22 | $83.22 | $78.22 | −$15.00 | 1,048 |
| BCBS-A - FEP (PPO) | $83.22 | $83.22 | $83.22 | $70.49 | −$12.73 | 447 |
| BCBS-A - CLIENT EMPLOYEE PLAN (PPO) | – | – | – | $90.49 | – | 273 |
Three separate Blues licensees, each negotiated by its own market.
| Market | Plan | Allowed, 99214 | Medicare | % of Medicare |
|---|---|---|---|---|
| Market A | BCBS-A | $76.22 | $100.35 | 76% |
| Market B | BCBS-B / Regence | $105.43 | $102.78 | 103% |
| Market C | BCBS-C | $107.57 | $106.44 MA | 101% |
Plain medians across all clinicians, so these will not match the provider-type-matched percentages in section 01. At Market C the comparator is Medicare Advantage, because Medicare FFS there pays the RHC all-inclusive rate.
| Item | Note |
|---|---|
| Two readings, both open | Either BCBS is paying under a live contract, in which case the difference is recoverable, or its published file is stale and it is posting a rate it no longer honors. The observed series steps down evenly ($88.22, $85.06, $80.49, $75.49) and the published $87.86 sits near the 2024 level, which is consistent with a stale file. The client does not need to settle which it is before asking BCBS to reconcile the two numbers against the contract. |
| An unexplained second tier | Every provider group in the file carries two rates in a constant 1.345 ratio ($87.86/$118.22, $81.80/$110.06, $78.77/$105.99). The place code is the placeholder CSTM-00 on every row and the billing class is professional for both, so the file does not say what separates them. The lower tier is used above. If any real volume prices at the upper tier, the shortfall widens. |
| Group A5 carries two odd rates | $34.86 and $53.63 on 99214 appear under the Group A5 tax ID and under no other entity. Excluded from the figures above and worth asking about separately. |
| Peer comparison | The 32 to 35 other in-state organizations quoted here appear in the file because one of the client’s clinicians is also listed under their tax ID, so they skew toward affiliated and former-employer groups rather than a clean sample of in-state practices. Directionally useful; not a market benchmark. For 99214 the range across them runs $72.71 at the lower quartile to $261.98 at the top. |
| What a machine-readable file is worth | These files are the payer’s own assertion and are known across the industry to carry rates for providers who are not really contracted. The match here is on exact tax ID from the client’s own records rather than on clinician number alone, which is the stronger of the two, but it remains the payer’s number until the contract confirms it. |
| Timing | The file is dated 2026-07-27. Paid medians cover dates of service August 2025 through July 2026, so they span both sides of the January reduction; the 2026H1 column in 02.2 is the post-reduction figure. |
| # | Code | Description | Payer | Mkt | 12mo vol | Allowed | Medicare allowed | % of Medicare | Annual gap | % of total gap |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214† | OFFICE VISIT- EST PT.- LEVEL 4 | BCBS | Mkt A | 36,731 | $76 | $91 | 83% | $554,395 | 34.6% |
| 2 | 99213† | OFFICE VISIT- EST PT.- LEVEL 3 | BCBS | Mkt A | 20,686 | $44 | $60 | 73% | $330,077 | 20.6% |
| 3 | 87428 | COMBO FLU A&B/COVID | BCBS | Mkt A | 2,776 | $33 | $69 | 48% | $99,409 | 6.2% |
| 4 | 99214† | OFFICE VISIT- EST PT.- LEVEL 4 | UnitedHealthcare | Mkt A | 11,723 | $84 | $92 | 91% | $94,398 | 5.9% |
| 5 | 99213† | OFFICE VISIT- EST PT.- LEVEL 3 | UnitedHealthcare | Mkt A | 6,765 | $50 | $60 | 84% | $66,221 | 4.1% |
| 6 | 99214† | OFFICE VISIT- EST PT.- LEVEL 4 | Cigna | Mkt A | 3,840 | $80 | $93 | 86% | $47,986 | 3.0% |
| 7 | 99214† | OFFICE VISIT- EST PT.- LEVEL 4 | Aetna | Mkt A | 2,896 | $78 | $92 | 85% | $40,071 | 2.5% |
| 8 | 87428 | COMBO FLU A&B/COVID | Medicare Advantage | Mkt A | 1,199 | $36 | $69 | 52% | $39,639 | 2.5% |
| 9 | 99213† | OFFICE VISIT- EST PT.- LEVEL 3 | Cigna | Mkt A | 2,081 | $48 | $60 | 80% | $25,666 | 1.6% |
| 10 | 87428 | COMBO FLU A&B/COVID | UnitedHealthcare | Mkt A | 620 | $35 | $69 | 50% | $21,204 | 1.3% |
| 11 | G0439† | ANNUAL WELLNESS VST; PPS SUBSQT VST | Medicare Advantage | Mkt A | 4,366 | $113 | $117 | 96% | $19,624 | 1.2% |
| 12 | 99213† | OFFICE VISIT- EST PT.- LEVEL 3 | Aetna | Mkt A | 1,488 | $48 | $60 | 80% | $17,918 | 1.1% |
| 13 | 83036 | GLYCATED HEMOGLOBIN TEST | Medicare Advantage | Mkt A | 3,479 | $4.95 | $9.52 | 52% | $15,899 | 1.0% |
| 14 | 99213† | OFFICE/OUTPATIENT VISIT EST | BCBS | Mkt C | 3,265 | $71 | $73* | 98% | $14,945 | 0.9% |
† matched on rendering provider type (methodology, section 07). Observed medians are in section 05 and the workpapers. * compared to Medicare Advantage where Medicare FFS pays RHC encounter rates (Market C E&M).
The medians in the sections above blend every plan a payer sells, so quote the plan, not the blend. On 99214 the BCBS blend is $76.22, but the largest single plan, BCBS-A (PPO) at 19,793 claims, pays $78.22; Blue Network 2 ($68.55) and the federal employee plan ($70.49) are what pull the blend down. Out-of-state BlueCard plans with 50 or more claims run $70.49 to $90.49 on the same code. Allowed amounts and the Medicare figure here are plain medians across all clinicians, so they differ from the provider-type-matched numbers in sections 01 and 03.
| Code · payer | Description | All-plan median | Medicare allowed | Plans |
|---|---|---|---|---|
| + 99214 · BCBS | OFFICE VISIT- EST PT.- LEVEL 4 | $76.22 | $100.35 | 141 |
| + 99213 · BCBS | OFFICE VISIT- EST PT.- LEVEL 3 | $45.13 | $65.02 | 113 |
| + 87428 · BCBS | COMBO FLU A&B/COVID | $33.07 | $68.88 | 49 |
| + 99214 · UnitedHealthcare | OFFICE VISIT- EST PT.- LEVEL 4 | $84.46 | $100.35 | 59 |
| + 99213 · UnitedHealthcare | OFFICE VISIT- EST PT.- LEVEL 3 | $47.78 | $65.02 | 41 |
Every payer's allowed amount on 99213 and 99214 as a percent of the same year's Medicare, 2021 to June 2026. These read lower than section 01, which spans 18 codes and separates physician from NP/PA claims; BCBS-A is 71% here and 89% there. The Humana line ends at 2025: its commercial volume runs under 500 charges a year on these codes and falls below the 30-charge floor in 2026. Its Medicare Advantage plans are in the Medicare Advantage line.
Right-edge changes are in percentage points of Medicare (red falling, green rising). Points need 30+ zero-balance charges per code per year; 2026 covers January through June; the marker is the annual physician fee schedule update.
One table per market; contracts differ by entity. Dollar figures are observed medians. Red = under 90% of Medicare; green = above 115%; bundled = packaged into another service, not priced separately; † = the percentage is matched on rendering provider type while the dollar figure beside it is the plain median across all clinicians, so a daggered percentage will not reproduce from the two dollar figures in its row (methodology, section 07).
| Code | Description | Billed 12mo | Medicare FFS | Medicare Advantage | Medicaid & managed Medicaid | BCBS | UnitedHealthcare | Cigna | Aetna | Other commercial & TPA |
|---|---|---|---|---|---|---|---|---|---|---|
| 99214 | OFFICE VISIT- EST PT.- LEVEL 4 | 175,634 | $100 | $101 114%† | $82 82% | $76 83%† | $84 91%† | $79 86%† | $81 85%† | $191 190% |
| 99213 | OFFICE VISIT- EST PT.- LEVEL 3 | 91,909 | $65 | $69 109%† | $54 83% | $45 73%† | $48 84%† | $47 80%† | $51 80%† | $103 159% |
| G2211 | VISIT COMPLEXITY INHERENT TO EVALUATI | 42,548 | $11.59 | $14.49 131%† | $12.95 112% | $14.49 127%† | $14.79 128%† | $13.77 120%† | $0.01 · policy | $18.19 157% |
| 99204 | OFFICE VISIT- NEW PT.- LEVEL 4 | 25,799 | $119 | $130 116%† | $125 105% | $133 120%† | $141 125%† | $117 103%† | $111 99%† | $183 153% |
| 96372 | THERAPUEUTIC | 23,660 | $10.13 | $11.59 114% | $16.39 162% | $23 229% | $27 268% | $18.66 184% | $14.95 148% | $24 238% |
| 81003 | URINALYSIS AUTO WO SCOPE | 18,599 | $2.20 | $1.33 60% | $1.13 51% | $1.60 73% | $2.16 98% | $1.16 53% | $1.69 77% | $4.30 195% |
| 93010 | ELECTROCARDIOGRAM REPORT | 16,248 | $6.25 | $7.26 116% | $6.61 106% | $10.37 166% | $8.94 143% | $8.20 131% | $8.67 139% | $22 347% |
| 87880 | STREP A ASSAY W/OPTIC | 15,913 | $16.20 | $9.73 60% | $8.27 51% | $16.53 102% | $11.02 68% | $7.40 46% | $12.40 77% | $32 195% |
| G0557 | ADVANCED PRIMARY CARE MANAGEMENT SERV | 14,913 | $40 | $42 124%† | $43 108% | $17.13 36%† | $47 129%† | – | – | $51 127% |
| 99203 | OFFICE VISIT- NEW PT.- LEVEL 3 | 14,775 | $79 | $78 100%† | $82 103% | $75 100%† | $80 100%† | $66 83%† | $67 90%† | $111 140% |
| 93000 | ELECTROCARDIOGRAM- COMPLETE | 14,249 | $10.04 | $11.92 119% | $12.72 127% | $18.05 180% | $19.29 192% | $13.42 134% | $13.77 137% | $32 319% |
| 87804 | INFLUENZA ASSAY W/OPTIC | 11,873 | $16.22 | $9.93 61% | $8.28 51% | $16.55 102% | $9.37 58% | $7.61 47% | $12.41 77% | $32 195% |
| 83036 | GLYCATED HEMOGLOBIN TEST | 10,943 | $9.52 | $4.95 52% | $4.86 51% | $6.93 73% | $6.67 70% | $5.06 53% | $7.28 76% | $9.70 102% |
| J1010 | INJECTION, METHYLPREDINISOLONE ACETAT | 9,702 | $3.73 | $3.76 101% | $4.66 125% | $4.66 125% | $4.40 118% | $4.80 129% | $4.80 129% | $5.28 142% |
| 87428 | COMBO FLU A&B/COVID | 8,511 | $69 | $36 52% | $32 46% | $33 48% | $35 50% | $53 78% | $73 107% | $66 96% |
| J1100 | DECADRON 1MG | 8,216 | $0.41 | $0.38 93% | $0.55 134% | $0.47 115% | $0.44 107% | $0.55 134% | $0.48 117% | $0.92 224% |
| 99232 | SUBSEQUENT HOSPITAL CARE | 8,056 | $53 | $66 125%† | $59 112% | $85 164%† | $77 144%† | $67 127%† | $63 118%† | $80 150% |
| G0439 | ANNUAL WELLNESS VST; PPS SUBSQT VST | 8,032 | $127 | $110 96%† | $104 81% | $112 98%† | $108 95%† | $110 86%† | $111 100%† | $110 86% |
First claim submission to the first payer payment posting on the claim.
| Payer group | Claims billed 12mo | Median days to first payment | Slowest 10% | Paid ≤30d | Paid ≤90d |
|---|---|---|---|---|---|
| + Employer, WC & institutional | 1,029 | 29d | 143d | 36% | 54% |
| + Aetna | 8,009 | 20d | 33d | 69% | 77% |
| + UnitedHealthcare | 32,374 | 17d | 29d | 71% | 76% |
| + Medicare FFS | 89,283 | 16d | 38d | 85% | 91% |
| + Medicare Advantage | 134,889 | 15d | 29d | 89% | 94% |
| + BCBS | 104,737 | 14d | 23d | 77% | 80% |
| + Medicaid & managed Medicaid | 92,717 | 13d | 21d | 83% | 87% |
| + Other commercial & TPA | 19,744 | 12d | 59d | 66% | 79% |
| + Military & VA | 8,967 | 9d | 27d | 81% | 87% |
| + Cigna | 12,390 | 8d | 31d | 71% | 77% |
| Payer group | Claims billed 12mo | Median days to first payment | Slowest 10% | Paid ≤30d | Paid ≤90d |
|---|---|---|---|---|---|
| + Medicare Advantage | 11,670 | 27d | 34d | 82% | 94% |
| + Other commercial & TPA | 5,554 | 27d | 93d | 42% | 61% |
| + Employer, WC & institutional | 3,262 | 26d | 77d | 44% | 73% |
| + Medicare FFS | 16,215 | 24d | 61d | 67% | 91% |
| + UnitedHealthcare | 5,098 | 21d | 41d | 61% | 73% |
| + Aetna | 1,892 | 18d | 39d | 65% | 72% |
| + BCBS | 13,830 | 17d | 31d | 65% | 71% |
| + Cigna | 3,474 | 14d | 37d | 63% | 72% |
| + Military & VA | 1,549 | 13d | 63d | 72% | 85% |
| + Medicaid & managed Medicaid | 13,747 | 9d | 32d | 83% | 90% |
| + Plan B1 | 5,920 | 9d | 20d | 75% | 78% |
| + Plan B2 | 7,178 | 4d | 64d | 62% | 68% |
| Payer group | Claims billed 12mo | Median days to first payment | Slowest 10% | Paid ≤30d | Paid ≤90d |
|---|---|---|---|---|---|
| Employer, WC & institutional | 182 | 212d | 212d | 3% | 23% |
| Other commercial & TPA | 1,143 | 33d | 128d | 27% | 49% |
| + UnitedHealthcare | 1,103 | 19d | 31d | 74% | 83% |
| + Medicare FFS | 12,127 | 16d | 27d | 86% | 90% |
| + Aetna | 1,096 | 12d | 27d | 82% | 86% |
| + Medicare Advantage | 9,719 | 10d | 29d | 90% | 95% |
| + BCBS | 11,775 | 10d | 21d | 80% | 83% |
| + Military & VA | 852 | 10d | 32d | 81% | 89% |
| + Medicaid & managed Medicaid | 21,454 | 10d | 27d | 84% | 89% |
| + Plan C1 | 935 | 9d | 31d | 81% | 88% |
| + Cigna | 713 | 7d | 42d | 65% | 75% |
Medians and p90 count paid claims; the percentage columns divide by all billed claims. A claim can resolve with no payer payment at all (deductible plans, capitation), so the percentage columns are not denial rates. Self-pay and provider-based-billing plans are excluded, as are payer groups under 100 claims. Window and recipe in methodology, section 07.
| Item | Note |
|---|---|
| Allowed amount | Athena's ALLOWABLE field is unpopulated in this data share, so allowed = payer payments + patient cost share (copay, deductible, coinsurance) on zero-balance charges (nothing left owing on the line, payer paid > 0). Validated against the charge-minus-contractual method; the paid-plus-cost-share figure is the stable one and matches the industry definition. |
| Medicare allowed | Median Medicare FFS allowed from the same data, per code per market: the payer's own adjudications, not an external fee schedule. Derived Medicare payments embed the 2% sequestration reduction, so the benchmark runs slightly below the published fee schedule and the gap is understated by the same margin. At Market C, Medicare FFS pays RHC all-inclusive encounter rates on E&M (identical $98.78 across visit levels), so E&M and G-code comparisons there use Medicare Advantage, which adjudicates at fee-schedule-like rates. |
| Rendering provider type | Medicare pays services billed under an NP or PA at 85% of the physician fee schedule, and each payer’s share of NP/PA visits differs, so on visit codes (99xxx/Gxxxx) physician (MD/DO/DPM) and NP/PA claims are compared separately, each to its own Medicare rate, then weighted by that payer’s own share. The Market A data reproduces the 85% rule to the cent (99214 NP/PA Medicare median $85.30 = $100.35 × 0.85). The NP/PA Medicare rate is derived as 85% of the physician median because the observed NP/PA Medicare medians at Market B and Market C contain RHC encounter rates. Provider-based-billing entities contribute no volume to these codes. |
| Gap math | Annual gap = the payer’s actual 12-month billed-claim count on that code × the per-claim difference (matched on provider type for visit codes, Medicare minus allowed elsewhere), provider-type strata priced below Medicare only, negotiated contracts only. Volumes are exact counts per payer × code, not apportioned estimates. Medicare Advantage counts as negotiated; Medicaid and managed Medicaid, TRICARE/VA and workers’ comp do not. |
| Volume basis | The gap prices the full 12-month billed volume at the per-claim difference. This values the contract terms; cash recovered in a year also depends on how much of that volume resolves with payment. Billed and zero-balance counts are side by side in the workpapers. |
| Zero-balance selection | Medians use zero-balance charges only, which could in principle skew toward claims that adjudicate cleanly. Two checks say it does not. Pricing the gap two ways: blending physician and NP/PA medians together gives $2.40M/yr for this window, while comparing the two separately, which is what the $1.60M headline uses, is the more conservative of the two. Rerunning the blended version on the mature July 2024 to June 2025 window, where every charge has had 13+ months to adjudicate, gives $1.72M/yr. That drop is rate change, not selection: BCBS-A (PPO) 99214 allowed $85.06 in the mature window versus $75.49 after the January 2026 reduction, while codes whose contracts did not move reproduce to the cent across both windows (UnitedHealthcare (State A) 99213 $52.78 in both; BCBS-A 87428 $33.07 in both). |
| Workpapers | Every modeled row (market, code, payer group, exact billed and zero-balance counts, median allowed, the Medicare rate, annual gap, and the physician and NP/PA splits behind provider-type-matched rows) is in redacted-rates-workpapers.csv, including the Medicare allowed rows, government and program payers excluded from the gap math, and bundled codes, each flagged with how it was treated. |
| Bundled codes | Code and payer combinations allowing under 20% of Medicare (e.g. Aetna paying $0.01 on G2211) are payment policy, not rates: flagged "bundled" and excluded from all math. G2211 also resolves on only ~2% of BCBS-A submissions: a claims-policy dispute worth raising separately. |
| Lesser-of check | Contracts typically pay the lesser of billed charges or the contracted rate, so a fee set too low would cap payment and look like a bad contract. Every code and payer combination was checked for payment at or above billed charges: only 3 hit 15%+, two of them RHC encounter-rate artifacts. The fee schedule is not capping payment; the contracted rates are the constraint. This scan was run separately and is not reproduced in the workpapers. |
| Contract terms | This report measures what payers paid, not what contracts obligate. Effective dates, escalator clauses and lesser-of language live in the client’s contract files and are the other half of any rate conversation. The January 2026 BCBS-A reduction in section 02.2 should be read against the contract in force at that date. |
| Medians & blending | Figures are medians per billed line, so J-codes reflect typical billed units. Payer groups blend plan products (PPO/HMO/exchange); section 03.1 breaks the highest-volume Market A codes down to the Athena insurance package so the numbers taken into a negotiation are plan-level, not blended. Each figure needs 8+ zero-balance charges. |
| Billed charges | Charges were used only to test for lesser-of exposure, not as a benchmark. A payer's allowed amount as a percent of billed charges carries no information the percent of Medicare does not: the charge appears in both the payer's ratio and Medicare's, so it cancels, and (payer % of charges) divided by (Medicare % of charges) equals the percent of Medicare exactly. the client's fee schedules also mark up inconsistently, from roughly 2x Medicare on venipuncture to 15x on urinalysis, so a percent-of-charges figure mostly reflects which codes a payer covers. A payer paid on a genuine percent-of-charges contract would need its own treatment; none of the negotiated groups here are. |
| Days to first payment | Section 06 takes claims first billed May 2025 through April 2026, so every claim has had 100+ days to be paid as of this pull. First billed = earliest FIRSTBILLEDDATE on the claim; first payment = earliest payer payment posting (payer-side, non-voided). Payer groups follow the same classification as the open-AR breakdown in section 08.1, with Plan B1, Plan B2 and Plan C1 split out to match the rate sections; self-pay and provider-based-billing packages are excluded. Medians and p90 are computed over paid claims; the ≤30d and ≤90d columns divide by all billed claims. |
$19.53M payer-side, $4.30M patient-side, 124,197 open claims, 16 entities. Worklists first, the full AR below.
| # | Bucket | Claims | Held $ | Next step |
|---|---|---|---|---|
| 1 | Never billed, service date under 90 days | 6,063 | $1,596,544 | Release now. These are keyed and coded but were never sent, and the filing windows are still open. |
| 2 | Never billed, service date over 90 days | 881 | $208,311 | Triage this week: at or past typical filing limits. File with proof of delay or write off deliberately. |
| 3 | Billed once, then returned to an internal hold queue, stale 180+ days | 9,760 | $1,792,065 | Work by kick reason. Manager-hold rows here have a median 181 days since last touch. |
| 4 | Billed before, held under 180 days | 6,375 | $1,419,234 | Routine review; watch that this bucket clears rather than aging past 180 days. |
| 5 | Hold on the secondary claim, not the primary | 5,732 | $306,633 | Same review as buckets 1–4; the hold sits on the secondary claim status, so these do not appear in the service-date buckets above. |
| Entity | Market | Claims | Held $ | Never billed $ | Median claim age | Median days untouched |
|---|---|---|---|---|---|---|
| Group A2 | Market A | 7,856 | $1,624,995 | $971,599 | 71d | 45d |
| Group B2 | Market B | 2,723 | $805,968 | $166,109 | 242d | 93d |
| Group A1 | Market A | 4,318 | $800,374 | $174,513 | 193d | 49d |
| Group C1 | Market C | 4,604 | $782,545 | $71,028 | 305d | 116d |
| Group A5 | Market A | 3,234 | $534,016 | $112,336 | 197d | 56d |
| Group A3 | Market A | 2,498 | $456,162 | $179,277 | 155d | 57d |
| Group A6 | Market A | 2,317 | $328,815 | $40,999 | 198d | 60d |
| Group B1 | Market B | 1,438 | $307,610 | $50,729 | 164d | 53d |
| Group C2 | Market C | 676 | $122,459 | $11,091 | 168d | 39d |
| Group B3 | Market B | 660 | $117,881 | $13,429 | 454d | 112d |
| Group C3 (PBB) | Market C | 582 | $103,725 | $13,167 | 256d | 65d |
| Group B5 | Market B | 115 | $16,888 | $0 | 532d | 239d |
The entity table counts claims with a hold or follow-up status on either the primary or secondary claim, so it totals $6,001,438 against the $5,322,787 hold-queue pool above, and $1,804,277 of never-billed dollars against the $1,804,855 in buckets 1 and 2.
Group A2 holds the most: $1,624,995, $971,599 of it never sent (4,033 claims, median age 71 days). Filing limits govern the timing here.
These four worklists cut across the full payer AR on their own criteria. They overlap the 180-day pool above rather than summing to it.
| # | Worklist | Claims | Payer $ | Next step |
|---|---|---|---|---|
| 1 | Billed 45+ days, zero response on file | 6,252 | $2,041,209 | Batch claim-status inquiries; confirm receipt, rebill what never landed. Median age 158 days. |
| 2 | Credentialing & enrollment kicks | 1,817 | $514,761 | One enrollment-team project: resolve the credentialing flag and e-submission enrollment, then rebill the list at once. |
| 3 | Claim-data error kicks | 801 | $256,351 | Coder rework queue: fix and resubmit; filing clocks apply to corrections. |
| 4 | Duplicates & review/appeal flags | 2,469 | $372,946 | Fast disposition pass: close true duplicates, decide appeal or adjust on the remainder. |
| # | Item | Dollars | Next step |
|---|---|---|---|
| 1 | Release the statement queue | $489,842 | Release the hold and mail the statements. No collections program required. |
| 2 | Work balances under 180 days first | $3,331,033 | Deductible-dominant ($987,272) and direct self-pay ($908,012) lead. Only $99,117 is on a payment plan today. |
| 3 | Decide the 181+ day balances deliberately | $973,603 | Agency placement or write-off, entity by entity; $178,683 is already at agencies. |