Imaging Centers: Plausibility and Coverage

1. Rate Object:

2. Plausibility:

   • What codes should we include for imaging centers?

3. Coverage:

   • Using TQ Spines, how is MRF coverage?
   • Can we use Definitive Network ID (e.g. Imaging Center ownership) to impute?

4. Benchmarks:

   • Use MPFS facility rates as a medicare benchmark for Imaging Centers.

Rate Object

• Add Imaging Center rate objects with facility = False and bill_type = 'Professional'.

Plausibility

The requirement is not to add all plausible codes, but to add enough codes to support Consumer. Therefore, we can add a limited set of codes used in radiology SSPs:

SELECT DISTINCT line_code
FROM tq_dev.standard_service_packages.ssp_sub_packages c
LEFT JOIN tq_dev.standard_service_packages.sub_package_contents s
    ON s.sub_package_id = c.sub_package_id
WHERE ssp_id LIKE 'RA%'
AND fee_type IN ('Professional Fee', 'Facility Fee', 'Optional Fee')
AND item_type IN ('package_line')

Coverage

SELECT 
    payer_name,
    product_network_label,
    COUNT(DISTINCT ic.provider_id) AS n,
    COUNT(DISTINCT ic.provider_id || cr.billing_code) AS n_rates
FROM tq_production.public_2025_06.core_rates cr
JOIN tq_production.spines.spines_provider_imaging_centers AS ic
    ON cr.provider_npi = ic.npi
WHERE cr.payer_id || product_network_label IN (
    '643CHOICE PLUS',
    '76NATIONAL OAP',
    '7OPEN ACCESS MANAGED CHOICE',
    '42NY PPO',
    '522KFHP NORTHERN CALIFORNIA'
)
AND ic.provider_type_rating in ('Likely', 'Highly Likely') 
AND ic.provider_active_status = 'Active'
AND billing_code IN (
    SELECT DISTINCT line_code
    FROM tq_dev.standard_service_packages.ssp_sub_packages c
    LEFT JOIN tq_dev.standard_service_packages.sub_package_contents s
        ON s.sub_package_id = c.sub_package_id
    WHERE ssp_id LIKE 'RA%'
    AND fee_type IN ('Professional Fee', 'Facility Fee', 'Optional Fee')
    AND item_type IN ('package_line')
)
GROUP BY 1,2

payer_name	product_network_label	n	n_rates
Aetna	OPEN ACCESS MANAGED CHOICE	1707	244868
Anthem	NY PPO	55	11770
Cigna	NATIONAL OAP	1050	169027
Kaiser Permanente	KFHP NORTHERN CALIFORNIA	109	23641
United Healthcare	CHOICE PLUS	1994	374338

Whether to use Definitive Network ID [No Need to Do This]

Adds ~300 more imaging centers, which may not be worth it.

WITH 
networks AS (
    SELECT 
        distinct
        payer_name,
        product_network_label,
        cr.billing_code,
        i.network_id
    FROM tq_production.public_2025_06.core_rates cr
    JOIN tq_production.spines.spines_provider_imaging_centers AS ic
        ON cr.provider_npi = ic.npi
    JOIN (
        SELECT distinct hospital_id, network_id, network_name
        FROM tq_raw.definitive.imaging_center_overview
    ) i
        ON ic.dh_hospital_id = i.hospital_id
    WHERE cr.payer_id || product_network_label IN (
        '643CHOICE PLUS',
        '76NATIONAL OAP',
        '7OPEN ACCESS MANAGED CHOICE',
        '42NY PPO',
        '522KFHP NORTHERN CALIFORNIA'
    )
    AND ic.provider_type_rating in ('Likely', 'Highly Likely') 
    AND ic.provider_active_status = 'Active'
    AND billing_code IN (
        SELECT DISTINCT line_code
        FROM tq_dev.standard_service_packages.ssp_sub_packages c
        LEFT JOIN tq_dev.standard_service_packages.sub_package_contents s
            ON s.sub_package_id = c.sub_package_id
        WHERE ssp_id LIKE 'RA%'
        AND fee_type IN ('Professional Fee', 'Facility Fee', 'Optional Fee')
        AND item_type IN ('package_line')
    )
)
SELECT 
    n.payer_name,
    n.product_network_label,
    COUNT(DISTINCT ic.provider_id) AS n,
    COUNT(DISTINCT ic.provider_id || n.billing_code) AS n_rates
FROM tq_production.spines.spines_provider_imaging_centers AS ic
JOIN (
    SELECT distinct hospital_id, network_id, network_name
    FROM tq_raw.definitive.imaging_center_overview
) i
    ON ic.dh_hospital_id = i.hospital_id
JOIN networks AS n
    ON i.network_id = n.network_id
WHERE ic.provider_type_rating in ('Likely', 'Highly Likely') 
AND ic.provider_active_status = 'Active'
GROUP BY 1,2

payer_name	product_network_label	n	n_rates
Aetna	OPEN ACCESS MANAGED CHOICE	2069	357972
Anthem	NY PPO	61	13054
Cigna	NATIONAL OAP	1317	222568
Kaiser Permanente	KFHP NORTHERN CALIFORNIA	412	89401
United Healthcare	CHOICE PLUS	2332	434679

Benchmarks

Use MPFS:

mpfs_rates AS (
    SELECT 
        CASE
            WHEN loc.state IN ('EK', 'WK') THEN 'KS'
            WHEN loc.state IN ('EM', 'WM') THEN 'MO'
            ELSE loc.state
        END AS state,
        mpfs.hcpcs,
        avg(facility_rate) as avg_facility_rate,
        avg(non_facility_rate) as avg_non_facility_rate
    FROM {{ cld_params.Tables.MPFS_MEDICARE_REFERENCE_TABLE.value }} mpfs
    JOIN (
        SELECT carrier_locality, max(effective_date) as effective_date
        FROM {{ cld_params.Tables.MPFS_MEDICARE_REFERENCE_TABLE.value }}
        GROUP BY carrier_locality
    ) latest
        ON mpfs.carrier_locality = latest.carrier_locality
        AND mpfs.effective_date = latest.effective_date
    JOIN (
        SELECT *
        FROM mpfs_localities
        WHERE rn = 1
    ) loc
        ON mpfs.carrier_locality = loc.carrier_locality
    WHERE (mpfs.mod = '' OR mpfs.mod IS NULL)
    GROUP BY loc.state, mpfs.hcpcs
)
SELECT 
    state,
    hcpcs,
    true as facility,
    avg_facility_rate as state_avg_rate
FROM mpfs_rates