What’s the process for calculating average total payments?
The cost data on this site comes from the Maine Health Data Organization’s All-Payer Claims Data (APCD) and represents claims data for the time period April 1, 2021 – March 31, 2022. CompareMaine does not include information on the uninsured or public payers (Medicare and MaineCare). A total of 9,036,067 healthcare claims from 29 payers were analyzed in the development of the payment estimates.
The payment estimates on CompareMaine are calculated based on the median total payment amounts reported by insurance companies submitting data to MHDO and serve as a reference point for comparison. MHDO makes every effort to provide accurate information on this website. Healthcare providers and insurance companies included on CompareMaine are sent the cost data to review for accuracy before they are released. Estimated payments presented on this website are within 10% of payer and facility estimated payments.
Medical payments are made using a few different methods, which can vary depending on the specific hospital and the specific payer. The major payment methods used in Maine are discount-off charges, ambulatory payment classification (APC), diagnosis related groups (DRG), and a payer-based fee-schedule. For a single procedure at a facility, it is possible that different payment methods were used by different insurance companies. This may result in variations in the median payments shown for each insurance company, more so than when all insurance companies use the same payment method.
Please contact your insurance company to find out your actual payment. If you do not have insurance, please contact the facility that you are most interested in for what you may be asked to pay.
The Steps MHDO Takes to Calculate Procedure Payments on CompareMaine
Step 1: Filter the Data
We filter the data by removing claims with missing information. We also remove claims from public payers (Medicare and Medicaid) and commercial claims for anyone 65 years old or older, as these claims are often paid for in-part by a public payer like Medicare. Including these claims would distort the average. We do not calculate a payment estimate for a specific procedure if the facility has fewer than 5 claims for that procedure in the APCD.
Incomplete Encounters: For procedures that require both professional and facility services, we remove from our estimates those patient encounters that do not include both a professional and facility claim.
Encounters Without Payment Data: We remove claims that do not have payment information.
Step 2: Find Claims Associated with a Test or Service
Next, we find the claims associated with a specific test or service. Depending on the procedure, the total payment can include:
Professional Payments: The portion of the payment paid to the healthcare provider, such as doctor or therapist, who provides direct services or procedures to a patient.
Facility Payments: The portion of the payment paid to the organization that provides healthcare services and procedures. This includes hospitals, surgical centers, diagnostic imaging centers, health centers, laboratories, and clinics.
Note: When more than one facility provides care, all facility costs are attributed to the facility with the largest portion of the payment.
The payment breakdown also displays:
Number of Procedures: How many procedures at the facility were used to calculate the payment estimate.
Count of Procedures: Approximately how many times the service or procedure was performed during the time period of interest for insured individuals (includes commercial and public payers).
Please visit All Payment Procedures to see which payments are included in each procedure.
Step 3: Calculate the Average Cost
We use the median value rather than the mean to calculate the average payment for each test or service at each facility. The median is the middle value when all items in a sample are sorted from lowest to highest, whereas the mean is calculated by adding up all the values and dividing by the number of items in the sample. The mean is affected by extreme values that are very high or very low compared to the rest of the sample. The median is less likely to be influenced by extreme values and therefore a better representation of the average payments.
When you use CompareMaine, you can filter costs by a specific insurance company. If you don’t choose an insurance company, the cost shown is the median payment for the test or service at the facility across all insurance companies reported in the MHDO’s APCD.
There are procedures that commonly occur with another procedure. In those cases, we estimate their cost together as a “bundled service.” CompareMaine has three categories of bundled services:
Bloodwork: Bloodwork procedures are bundled with the cost of the blood draw (CPT Code 36415) and transportation of the sample to a lab when necessary (CPT Code 99000).
Non-Bloodwork Labs: Non-Bloodwork labs are bundled with the payment for transportation of the sample when necessary (CPT Code 99000).
Skin Lesions: There are two skin lesion procedures on CompareMaine:
- Removal of Precancerous Skin (CPT Code 17000): This is bundled with the payment of the office visit in which the removal occurs and must include at least one of the following CPT codes in each code set (CPT Codes 99385-99386, 99395-99396, 99202-99205, 99211-99215, 99381-99384, 99391-99394, 99241-99245), the biopsy (CPT Code 88305), and the pathology exam (CPT Codes 11102, 11104, 11106).
- Removal of Noncancerous Skin (CPT Code 17110): This is bundled with the payment of the office visit in which the removal occurs and must include at least one of the following CPT codes (CPT Codes 99385-99386, 99395-99396, 99202-99205, 99211-99215, 99381-99384, 99391-99394, 99241-99245).
Emergency Department Visits
There are five Emergency Department (ED) CPT Codes:
- Emergency department visit, very minor (CPT Code 99281)
- Emergency department visit, low complexity (CPT Code 99282)
- Emergency department visit, moderate severity (CPT Code 99283) – represents 28.2% of ED claims in Maine’s APCD
- Emergency department visit, problem of high severity (CPT Code 99284) – represents 37.4% of ED claims in Maine’s APCD
- Emergency department visit, problem with significant threat to life or function (CPT Code 99285)
We calculate estimates for ED visits based on claims from the same member on the same day that have any of the five ED CPT Codes listed above. The “lead code” is the CPT Code associated with the facility component of the claim, while the professional component can be any of the five ED CPT Codes. For example, if the facility component of an ED episode is CPT Code 99283, the claim will be associated with that CPT Code, regardless of if the professional component is CPT Code 99821, 99282, 99283, 99284 or 99285.
Services Measured in Time Increments or Units
There are services like physical therapy (PT) or occupational therapy (OT) that are measured in time increments, referred to as “units”. These units typically represent 15 minutes of therapy. You may receive multiple units of different types of therapy during one appointment. For example, you may receive 30 minutes (two units) of therapeutic exercise and 15 minutes (1 unit) of ultrasound therapy. To estimate the payment in this scenario, we look at the entire visit and multiply the payment of therapeutic exercise by 2 units and the payment of ultrasound therapy by 1 unit and then add the two payments together.
Patients often receive multiple types of treatment in a physical or occupational therapy appointment and the type of service provided may change over the course of treatment. If you have more than one therapeutic service during the same visit, you will need to look up each service separately. Your PT or OT provider can provide information about what services, including the number of units of each service, will likely be billed during your course of treatment.
Example: Calculating Payments Using the Median
In this example, the payments are the same at the two labs for the first four patients’ blood tests. However, Patient E’s blood test costs $200 more at Lab 2 than at Lab 1. The median or middle value stayed the same at the two labs. But the mean payment for blood testing is $40 more at Lab 2 (bumped up by the more expensive testing for one patient, Patient E). The median payment, $100, is a better example of what blood testing costs.
|Lab 1 Costs
|Lab 2 Costs
|Patient A's Blood Test
|Patient B's Blood Test
|Patient C's Blood Test
|Patient D's Blood Test
|Patient E's Blood Test
|Total Sum of Blood Testing
|MEDIAN Cost (middle value in list, Patient C)
|MEAN (Total Sum/Total Number of Tests)
Step 4: Link a Payment to a Facility
Finally, we determine which facility the payment should be assigned to. For example, if you go to the hospital for an MRI, there will be a cost that is paid to the hospital (facility) and a cost that is paid to the radiologist (professional) that reads the MRI. In the scenario where more than one facility provides care, the facility with the largest portion of the payment is identified as the "Lead Provider" and all facility payments are attributed to them.