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Let’s thrust an often overlooked MRF column into the spotlight: negotiated type. How do payer postings differ in their use of this column? Can we use this column to see how often providers are taking a seat across the negotiation table from payers? Which procedures are being reimbursed under a fee schedule versus a negotiated rate? In this post, we’ll explore a subset of data containing Medicare reimbursable CPT codes found in the MRF postings for Aetna Open Access Managed Choice, Cigna National OAP, and United Healthcare Choice Plus. Additionally we’ll focus only on MRF records indicated as reimbursed under a fee-for service arrangement.
At a macro level, we see some interesting observations. This table provides a breakdown of the total number of unique CPT codes that have at least one record marked with a negotiation type of “fee schedule” or “negotiated” (Note: This data was collected using the February 2024 MRF postings).
| payer |
“fee schedule” CPT count
|
“negotiated” CPT count |
|---|---|---|
| Aetna | 5335 | 5367 |
| UnitedHealthcare | 0 | 5378 |
| Cigna | 5206 | 2908 |
United Healthcare doesn’t seem to be publishing any records with a negotiated type of “fee schedule”. Cigna on the other hand appears to be publishing the fewest number of codes that are being negotiated with providers. Aetna seems to have a balance in the number of codes that are negotiated or reimbursed under a fee schedule.
Next we take a look at the fraction of providers that are reimbursed under negotiated a rate versus under a fee schedule. Across all codes, around 17% of providers are reimbursed at a negotiated rate in the Aetna data. This same figure is at 3.5% for Cigna. Note that since United Healthcare doesn’t publish rates indicated as being reimbursed under a fee schedule, the fraction for them is 100%. In the Aetna data, the code that seems to be most frequently negotiated is CPT 81471 (genomic sequencing lab panel) where we see around 96% of all providers appear to have a negotiated rate. In the Cigna data, the code that seems to be most frequently negotiated is CPT 0523T (cardiac catheterization imaging analysis) where we see a whopping 98% of all providers appear to have a negotiated rate.
Taking a deeper look at a specific commonly searched CPT code, 27447 (knee arthroplasty), we see that Aetna’s data for this particular code seems to have the best coverage on negotiation type. A gut check on a comparison of the mean and median reimbursement rate from Aetna checks out as we see the “negotiated” rates are slightly higher than the “fee schedule” rates. For Cigna and United Healthcare we observe that each payer only appears to have coverage for one of the two negotiated types relevant for this analysis: Cigna only publishes rates for “fee schedule” whereas United Healthcare only publishes rates for "negotiated". It’s noteworthy that the mean and median for Cigna and UHC appear to be between the mean and median of the Aetna “fee schedule” rates and Aetna “negotiated” rates, which indicates that the true negotiated type may not be published accurately by these payers for this particular CPT code.
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