A key set of questions for any healthcare provider looking to expand their presence is: 

• Which markets should we expand to?
• For those markets, with which plans should we go in-network?  
• What is the opportunity size by market / plan? 

For an analysis like this, typically a payer strategy or development team evaluates the size of the target patient population in each market, competitive intensity, and other factors that determine their ability to win (e.g., investment needed, regulation, physician availability, etc.)

Until recently though, such an analysis would miss a key piece of the puzzle: actual contracted allowed amounts for peer organizations by key procedures / services. Incorporating what the reimbursement landscape looks like helps providers understand if the unit economics for a given market would even be feasible before committing any investment.

Recently, we went to the national Ambulatory Surgery Center Conference (ASCA) in Orlando and heard many groups are struggling with this very issue so let’s walk through how Serif and the payer price transparency data can help. 

Market benchmarks in Signal

In Signal, Serif Health enables our users to build customized market benchmark reports for this very need. In a time-frame of seconds, you can quickly evaluate the reimbursement landscape across the U.S. and then deep-dive into specific payers, sub-regions, and folks’ negotiated contracts with a few clicks. 

To begin, you can type in a code (or multiple) – e.g., 27447 for an outpatient knee joint surgery – and see for each state what the distribution of facility reimbursement looks like, filtered for just ASCs: 

Now let’s say after pairing this view of managed care reimbursements with the other factors mentioned above – e.g., potential volumes / market demand – the ASC group determines they want to look at Texas as a place to expand.

Inside the same report, you can double-click into specific payers in Texas to see what their contracts look like for 27447 across Ambulatory Surgery Centers:

Continuing with our example, after looking at reimbursement rates and pairing it with payer market share data on number of lives managed by each carrier in Texas, the ASC group determines to pursue BCBS Texas as a key payer to go in-network with. With one click, you can see which ASCs have negotiated what rates to prepare for an upcoming contracting discussion:

Seeing these entities who have preferred reimbursement helped the ASC determine where in Texas they should set up their first site but to ensure you are being comprehensive you can also search specific subregions inside Texas like San Antonio and see the reimbursement distribution accordingly: 

With these tools, Serif Health has helped countless payer strategy and business development teams gain the market intelligence and insights for their expansion decisions and refresh their perspective as the reimbursement landscape evolves over time. If you are interested in learning more about the payer price transparency data, feel free to reach out directly at sales@serifhealth.com or book time using this link.