Methodology, sources,
and computation.

// 01Data sources

Four public inputs are composed for every benchmark. Each is independently auditable. Each carries a federal mandate or a federal license. No private aggregator. No scraped panel.

// 02Computation

For every CPT code returned for your practice, we compute four anchors and one variance.

The four anchors

The peer band is computed across all NPIs sharing your specialty (taxonomy code) and state. We exclude rates outside the 5th–99th percentile to defend against MRF parsing errors and stale provider-reference IDs.

What "underpayment" means in our model

An underpayment is any CPT/payer pair where your observed contracted rate sits below the peer 50th percentile for your specialty/state. We surface three flavors:

• Mild gap, your rate is 4–10% below peer p50. Negotiable at next contract renewal.
• Material gap, your rate is 10–20% below peer p50. Worth a mid-cycle rate-review letter.
• Severe gap, your rate is >20% below peer p50 or below the CMS PFS floor. Often a coding/contract drift, not negotiation, fixable with a formal amendment request.

// 03Locality (GPCI) adjustment

Commercial rates vary dramatically by metropolitan area, a 99213 in Manhattan is not a 99213 in Modesto. We use the CMS Geographic Practice Cost Index (GPCI) to normalize for cost-of-practice differences. Your practice ZIP is mapped to one of the 112 CMS payment localities, and the resulting GPCI vector (work, practice-expense, malpractice) is applied to the CMS PFS anchor.

// 04Refresh cadence

Rates are updated monthly. Every health insurance issuer must publish a refreshed in-network MRF on the first business day of each month (45 CFR § 180.50(d)(5)). Our ingestion crawler picks up the new files within 48 hours of publication, re-runs the parse, and updates the rate index. The last successful payer ingest before this page was rendered: 2026-05-11.

• Daily, NPI Registry deltas (new providers, address changes, deactivations)
• Monthly, TiC MRF rate refresh per payer
• Annually, CMS PFS conversion factor + GPCI vector + RVU file (CY-rollover, every November)

// 05Confidence level definitions

Every benchmark we surface carries a confidence label so you know how much weight to put on it before taking action. The label is driven by source coverage, row count, and match quality behind the peer band, not by opinion.

• High Confidence. Strong source coverage, sufficient row count, and a clear payer/code/geography match. The benchmark reflects a meaningful sample of publicly available contracted rates for this combination. Use it as a primary anchor in a contract negotiation.
• Moderate Confidence. Useful directional insight. Some matching limitations or thinner source depth exist. The estimate is meaningful but should be verified against your actual contract language before using it as the sole basis for a contract ask.
• Low Confidence / Thin Sample. Limited data coverage, thin sample, partial match, or heavy benchmark assumptions. Treat as directional only. We surface it with an explicit "thin sample" or "low confidence" label rather than masking it behind an unqualified number.
• Processing. Data is being normalized, refreshed, or reviewed. Shown only with a "still ingesting" badge. Results will populate when the current ingest cycle completes.
• Unavailable. ReimburseOS does not currently have enough reliable data to calculate this result. We show this label instead of guessing or substituting a specialty average as if it were practice-specific.

// 06Data basis

Every number in a ReimburseOS output is calculated using one of four distinct data basis types. The basis is labeled on every result so you know exactly how a figure was produced.

• Exact TiC Public Contracted Rate. We found a publicly filed contracted rate in a payer's federal Transparency-in-Coverage MRF that matches your NPI, payer, CPT code, geography, and available payer-file identifiers. This is the strongest basis available from public data. It reflects what the payer has stated the negotiated rate is for your provider category in that market.
• User-Entered Practice Rate. You entered your own current reimbursement, average allowed amount, or expected rate. We use your number as the "your rate" baseline and compare it against the public benchmark. Your number is never overridden or substituted by our data.
• Benchmark Estimate. We estimated the opportunity using CMS Physician Fee Schedule locality adjustments, GPCI factors, commercial-to-Medicare benchmark research, specialty assumptions, payer mix, and available public market data. Labeled clearly so you know it is directional, not a confirmed contract figure.
• Unavailable / Low Confidence. We do not have enough reliable source data to confidently calculate this result. We label it "Unavailable," "Thin sample," or "Low confidence" rather than substituting a guess. No specialty average is presented as practice-specific.

// 07NPI/TIN matching

Matching public contracted rates to a specific provider involves NPI, group structure, taxonomy, geography, and network relationships. Federal TiC MRFs use several different provider-reference structures depending on the payer: some identify providers by NPI directly, others by TIN, group NPI, or payer-specific provider-reference IDs that must be resolved against a separate provider-reference file.

Where exact TIN-level matching is required and unavailable, results are labeled accordingly. Healthcare buyers understand that rate matching depends on multiple identifiers. We surface what we can confirm and label everything else. If a payer file contains sparse or ambiguous provider references for your NPI, the result will carry a lower confidence label rather than a fabricated exact-match figure.

Improving match quality is one of the primary reasons payers continue refining their TiC MRF structures under CMS guidance. Our ingestion pipeline tracks schema changes and updates matching logic with each monthly refresh.

// 08Benchmark sources

Every benchmark figure in a ReimburseOS Snapshot or Practice Audit traces to one or more of the following public sources:

• CMS Physician Fee Schedule (PFS) 2026. Per-CPT RVU-based allowed amounts using the CY2026 final rule conversion factor. The Medicare-allowed amount is the locality-adjusted floor against which commercial contracted rates are compared.
• CMS GPCI locality adjustment. Geographic Practice Cost Index applied across 112 CMS payment localities. Normalizes the PFS benchmark for cost-of-practice variation across metropolitan areas and rural geographies.
• Federal Transparency-in-Coverage MRFs. In-network rate files published monthly by every major commercial payer under 45 CFR § 180.50. The primary source for peer percentile bands and confirmed contracted-rate lookups.
• NPI Registry (NPPES). Provider specialty taxonomy, practice address, and group affiliation used to match rates and build peer cohorts.
• Commercial-to-Medicare benchmark research. Published research on median commercial-to-Medicare rate ratios by specialty and geography, used to calibrate Benchmark Estimate calculations where TiC data coverage is thin.

No proprietary aggregator data is used as a primary source. No private claims database is used. Every benchmark is traceable to a federal mandate or publicly available research. When a source is insufficient for a given combination, the result is labeled Unavailable rather than filled from an opaque model.

// 09Limits and what we don't claim

The benchmark layer is precise about contracted rates. It does not, and cannot, know everything about how a practice runs. We surface what we have. We label what we don't.

• We report documented reimbursement opportunity, not realized recovery. Negotiation outcomes depend on you, your payer relationships, and your contract terms.
• We surface contracted rates from public MRF filings. We do not have visibility into your remittance advice unless you choose a paid workflow that supports it.
• We do not know your patient mix, your internal billing realities, your modifier patterns at the encounter level, or payer-specific authorization rules.
• Some payers publish incomplete MRFs (missing modifier rows, missing place-of-service variants, sparse provider-reference resolution). When we can't confidently match your NPI, we say so in the Snapshot rather than guessing.
• Coverage expands continuously. Regional plans, Medicare Advantage, and state Medicaid MCOs are ingested as new TiC MRFs become available. We mark data "unavailable" rather than estimate when coverage is thin for a specific CPT/payer/state combination.

How to interpret a result

A gap is a starting point, not a verdict. If a CPT and payer pair shows up below peer p50, the right next move is to compare that rate against your actual contract language, your fee schedule attachment, and your last renewal letter. The Snapshot tells you where to look. The Practice Audit and counteroffer memo turn that into a negotiation package.

What ReimburseOS does NOT know

• Anything about your patients.
• Your real-world payer mix or volume by code.
• Your contract clauses (carve-outs, multi-procedure reductions, modifier policies) unless you submit them on a paid tier.
• Whether a payer will agree to renegotiate. We surface leverage. We don't promise outcome.

Snapshot delivery

Results appear in your browser in about 15 seconds. No email required. No credit card. No PHI.

// 10Corrections policy

If you can show that a rate in our Snapshot is wrong, wrong CPT, wrong payer, wrong locality, stale MRF version, write info@reimburseos.com. We will re-run the parse, post the correction, and credit any paid Snapshot affected by the error. No NDA. No PR cycle. Methodology is the moat.