It’s no secret that out-of-network medical charges and bills are the bane of American consumers. Such charges and bills are worryingly common and often vary wildly. found, for example, that charges for a circumcision range from $252.00 to $7,532.10.

What is Data iSight?

To tackle the problem of out-of-network charges, ϲ developed our Data iSight pricing methodology. Unlike Usual and Customary (U&C) or Medicare-based repricing solutions, our methodology recommends reductions using both a cost-up approach (for facility claims) and median reimbursement levels (for practitioner claims) to achieve maximum defensibility, wide provider acceptance, and savings of 61%-81% off billed charges.

How does Data iSight work?

Data iSight takes different approaches to repricing out-of-network charges depending on the type of claim. If repricing a facility claim, the methodology uses a cost-up approach that looks at the median cost for procedures at facilities of a similar size, location and type. If repricing practitioner claims, a median reimbursement approach is used. All methodologies consider factors like severity levels, incorporate claim editing and are confirmed by an industry statistician for validity and defensibility.

When does Data iSight apply to a claim?

Data iSight applies to out-of-network, non-Surprise Bill claims that have been billed but have not yet been paid.

What are the benefits of Data iSight?

For payors, the key benefits of the methodology are provider acceptance rates of 89%-98%, high defensibility and savings of 61%-81% off billed charges.

We achieve high acceptance rates through our emphasis on transparency. When accessing one of three secured websites designed for different audiences, the members, providers and clients receive a detailed explanation of the Data iSight pricing methodology for their particular claim. The explanation includes provider charge and cost, benchmark group comparison (charge and cost, number of cases, number of facilities), Medicare payment comparison and appropriate reimbursement for facility claims; and median reimbursement and Medicare payment comparison on practitioner claims.

Further contributing to our high acceptance rates is our collaborative approach to working with providers. Our team engages directly with providers and members to educate them on our reimbursement methodology and negotiate a settlement with the provider, if needed. Clients have different options for how they would like us to handle appeals/inquiries. Our team can 1) hold firm to the Data iSight reimbursement recommendation, 2) negotiate upon provider appeal or 3) require reversal on appeal if a negotiated settlement cannot be reached.

With regard to members, the key benefits of Data iSight relate to balance bills. Because Data iSight provides a fair and reasonable reimbursement, providers are less likely to balance bill members. If they do, ϲ offers optional patient advocacy services at no additional charge.

Providers will often object to other repricing services on the grounds that the repriced claim amount doesn’t take into consideration the unique characteristics of their facility. They may also say that the repriced claim from other reference-based repricing services amount is so low that they cannot turn a profit. Because Data iSight takes into consideration similar facilities (in terms of size, type and location) and uses widely recognized data for professional claims, providers can rest assured that they are receiving a fairly repriced claim.

What are some common misconceptions about Data iSight?

Some providers mistakenly believe that Data iSight prices are based on a percentage of Medicare, a percentage off of billed charges or U & C pricing. Unlike other methodologies, we use comparative data to determine median cost or median reimbursement amounts. This ensures fair reimbursements for providers.

Another misconception is that Data iSight generates high appeal rates. In fact, our appeal rates are between 2% and 11%.

How is Data iSight different from other pricing solutions?

Data iSight’s main competitors base their methodologies on either U & C pricing or Medicare.

With U & C pricing, bills tend to grow larger and larger over time as the definition of “usual and customary” is set by what providers charge in a specific geographic area. In order to be statistically valid, Data iSight uses national data that includes over 3 billion transactions from 55 million unique patients and more than 90 diverse payors. It then adjusts costs for like providers on a local level using the wage index and Medicare reimbursement data.

Medicare-based pricing solutions are based on a percentage of the amount the Centers for Medicare and Medicaid Services (CMS) allows. CMS’s reimbursement calculations include a single conversion factor that is applied to all claims regardless of service category (Surgery, Radiology, Pathology, Medicine, Evaluation and Management, Emergency Room and Physical Therapy). Data iSight, on the other hand, applies different conversion factors to service categories based on their code groups. In fact, Data iSight recently refined the methodology to apply 107 unique conversion factors to subcategories of services. These dynamic conversion factors are derived from actual commercial paid claims database to determine a median reimbursement amount, making it even more defensible against appeals. Moreover, since Medicare is designed for a population of people over the age of 65, it does not account for the types of claims that would occur in a younger population. This means that many claims can’t be priced using a Medicare-based methodology. With Data iSight, only 1.5% of charges can’t be priced.

When should payors consider implementing Data iSight?

Commercial plans of any size that value discounts on out-of-network charges with low provider abrasion should consider implementing Data iSight into their hierarchy of repricing services. By strategically placing Data iSight in their hierarchy, payors can maximize savings while minimizing the balance billing of their members. Data iSight is also flexible, allowing clients to apply it to only specific claim types or service categories, with different options for appeals handling based on plan language.

Where can I learn more?

To learn more about how Data iSight can help reduce out-of-network costs, co.