New health insurance “transparency data” looks suspiciously wrong
There are two problems here:
1) Hanlon’s razor
2) The author doesn’t understand health insurance data.I’m not trying to excuse the other bad behavior, but within the data itself, he’s experiencing a combination of health insurers’ incompetence, the kludged up data models they’ve had to build to represent the output of the multiple generations of claims processing systems and other administrative processes, and the general mess that provider identifiers are. Every payor calculates values differently. Every payor uses different codes (beyond the standard CMS and CPTs). Every payor has different arrangements that are difficult to represent in standard schema, eg capitation in Florida, delegation in California, or the oddness that are Taft-Hartley plan.There is a link in the article to a discussion with CMS. Another participant in the discussion works for IQVIA, a long-time claims data aggregator (and CRO and a bunch of other things), and clearly understands what’s going on. It would be extremely difficult to do this work at all without significant experience working with multiple payors’ data, which requires time and access, and pays well once you do have that specialized experience.