Excited to dive into transparency data from health insurance payers we asked a speech language pathologist for a few CPT codes she billed regularly. Armed with 3 CPT codes: 92507, 92522, and 92532. We focused on negotiated rates from Blue Cross and Blue Shield of North Carolina as they command around 80% of market share in both the individual and group spaces in the North Carolina.
Payer Transparency Files Can Seen Overwhelming
Working with transparency data from payers is not for the faint of heart. These files are massive and include thousands of codes, arrays, modifiers, and more. Domain knowledge is exceedingly important when analyzing this data to ensure meaningful insights.
In reviewing transparency files from various payers, it might seem as if payers are intentionally making the files complex to discourage use. However, the reality is less sinister: payer claims processing systems and provider rate structures are highly complicated. A single negotiated rate file can contain trillions of records and combinations of procedures and providers, many of which are unrelated to a given provider’s scope of practice. For example, knee replacement rates may appear for a gastroenterologist or colonoscopy rates for a mental health provider.
Further complicating matters, one NPI can have multiple rates for the same CPT code, likely due to different benefit plans with varying reimbursement rates. Unfortunately, the machine-readable files do not include network labels to explain this variation. This deep domain knowledge is what sets Hannalytics apart.
Population Overview – Speech Language Pathology in North Carolina
Let’s examine the study population and how the rates for our study codes (92507, 92522, and 92523) fall within North Carolina.
Categorization Logic
| Well Below Peers | Reported negotiated rate is more than 2 standard deviations below the mean. |
| Below Peers | Reported negotiated rate is between 1 and 2 standard deviations below the mean. |
| In Line with Peers | Reported negotiated rate falls within 1 standard deviation above or below the mean. |
| Above Peers | Reported rate is between 1 and 2 standard deviations above the mean. |
| Well above Peers | Reported rate is more than 2 standard deviations from the mean. |
The mean negotiated rate in the study for CPT code 92507 is $69.80, with the most frequent rate at $73.10. As of March 2024, this aligns closely with the Medicare rate of $73.53. The NC Medicaid rate is $66.20, which has remained unchanged since 2022.
For CPT code 92522, the mean negotiated rate is $106.89, with the most frequent rate at $106.13—slightly below the current Medicare rate of $107.07. NC Medicaid reimbursement is $73.79 and has been unchanged since 2022.
The mean negotiated rate for CPT 92523 is $219.85, with the most frequent rate at $217.73. This rate is also close to the Medicare rate of $219.43, while the Medicaid reimbursement stands at $153.07.
Over 50% of speech-language pathologists in the study have negotiated rates as follows, representing the most prevalent rate set:
| CPT Code | Most Frequent Negotiated Rate |
| 92507 | $73.10 |
| 92522 | $106.13 |
| 92523 | $217.73 |
In the example above, the current rate is indicated by the dotted reference line. For CPT 92507, this is well below the most frequent rate. Is there an opportunity here to negotiate for equitable rates? Below take a look at the most frequent rates seen in the study by rate count.
Top 5 Rates by CPT Code in Study
Bottom Line: If your rates are lower than the most frequent rates outlined above, you may not be receiving reimbursement in line with your peers.
Do you know where your rates fall?
