In a professional discipline so reliant on “knowns” composed from data, evidence, and patterns, healthcare providers find themselves in new territory. Several months into the COVID-19 crisis, much is still being learned about this new virus. The long-term effects are a question mark on several fronts. We have yet to understand the potential impact on public health, the economy and public policy.

Providers have been dealing with cost pressures for years, and the current crisis has only served to amplify them: Social lockdowns and massive unemployment rates make going to the doctor a risk and expense that many Americans are choosing to forego.

Telehealth services have helped pay the bills, but current medical reimbursement policies are considered to be temporary emergency measures. CMS continues to assess telehealth payment rates and how those services should be made permanent once the crisis passes.[1]

The Power of Medical Reimbursement Insights

Despite so many unknowns, now is the time for providers to take stock of their health system’s financial position and make proactive decisions around setting service rates, negotiating contracts, and mapping potential expansion opportunities. A good first step? Accessing comprehensive data on medical reimbursements.

For example, LexisNexis® MarketView Reimbursement Insights gives providers an unprecedented “peek behind the curtain” on the actual amounts insurers paid to providers by service and/or geographic area. This information can clarify a path forward in three ways:

  1. Uncover opportunities for expansion: either new services or locations. 
    Where are patient needs not being met? How can we fill gaps to deliver more convenient access, improve population health, and provoke the cost benefits of competition?

    With a clear picture of the actual volume of services performed within specific ICD10 and HCPCS codes by location and rates paid per payer, providers can better determine the economic potential of adding new capabilities like telehealth or an in-house laboratory; opening new physical locations; and investing in new equipment. This information also helps demonstrate Certificate of Need.
  1. Benchmark rates for services.
    Rate transparency opens a whole new view of how the market is changing. For example, the explosive growth of free-standing, independent imaging facilities spurred one of the nation’s largest insurers to drive patients away from hospitals in lieu of these less expensive providers.[2]

    And in 2018, CMS began providing Medicare reimbursement to providers who collaborate with diabetic patients through smartphone-enabled continuous glucose monitors.[3] Seeing, in actual dollar amounts, the influence of these market dynamics on provider revenue offers a chance to level-set pricing to bolster competitiveness.

    Additionally, reimbursement billing codes can provide a testament to a provider’s quality outcomes by revealing, for example, lower readmission rates or hospital acquired infections over other market providers. This can greatly enhance negotiating power.
  1. Reduce referral leakage and procedural splitting.
    According to one healthcare industry estimate, providers may be losing as much as 55% of potential business to competitors.[4] A comprehensive market view through medical reimbursement data makes it easy to see where health system physicians are referring or providing procedures out-of-network so that steps can be taken to recapture this precious revenue.

These are extraordinary times for healthcare practices and hospitals. Data-driven insights offer a reliable guidepost for strategic decisions that help shore up provider resiliency and strengthen market positioning.

MarketView Reimbursement Insights leverages some of the industry’s most current, comprehensive, and highly accurate deidentified medical claims data universe, delivering valuable market intelligence to healthcare organizations.

Want to learn more? Read our Executive Summary: The Top Three Reimbursement Insights Your Data Offers.


[1] Health Affairs blog post by Seema Verna, Administrator-Centers for Medicare and Medicaid Services, “Early Impact of CMS Expansion of Medicare Telehealth During COVID-19,” July 15, 2020

[2] King & Spalding, Health Plans’ Use of Policies and Guidelines to Reduce Coverage and Reimbursement, March 8, 2019

[3] mHealth Intelligence, CMS Embraces mHealth With Reimbursement for Smartphone CGM Links, June 13, 2018

[4] College of Healthcare Information Management Executives, Webinar: How Can IT Help Reduce Revenue Leakage, January 30, 2019