Counterparty Validation

The highest confidence signal: payer and hospital independently report similar rates for the same ROID. A match earns score 7.

The Logic

For each payer rate column, check if it matches any hospital rate within ±20% (or ±10% for rates above $15,000). And vice versa for hospital rates.

Counterparty Validation

-- Counterparty Validation (Score = 7)
-- Highest confidence: payer and hospital independently agree

-- For a PAYER rate, check against ALL hospital rates:
CASE WHEN
  any_match(
      filter(hospital_rates_array, h -> h IS NOT NULL),
      h ->
          -- Match within +/-20% (or +/-10% for rates > $15k)
          ABS(payer_rate - h) <= CASE
              WHEN payer_rate < 15000 THEN 0.20 ELSE 0.10
          END * payer_rate
          OR
          ABS(payer_rate - h) <= CASE
              WHEN payer_rate < 15000 THEN 0.20 ELSE 0.10
          END * h
  )
  -- Must ALSO pass outlier bounds for this bill type
  AND rate BETWEEN medicare_lower AND medicare_upper
THEN 7 + (rate / 1e8)    -- 7.xxxxx: tiny tiebreaker for higher rates
END

-- For a HOSPITAL rate, same logic but checks payer_rates_array
-- Symmetric: both directions must pass for Score = 7

Walk-Through: Counterparty Validation

Code 99213, Provider X, Payer Y

Setup: Code 99213, Provider X, Payer Y

Payer reports: $1,000 (negotiated rate)

Hospital reports: [$950, $1,050, $2,000] (array from different methodology columns)

Check payer $1,000 vs hospital array: vs $950: |$1,000 − $950| = $50 ≤ 20% × $1,000 ($200) — MATCH

Also check: Must pass outlier bounds (0.5–30× Medicare for non-IP) — $1,000 is within bounds.

Score = 7 + ($1,000 / 1e8) = 7.00001 (validated) The /1e8 tiebreaker: among validated rates, higher dollar rates are slightly preferred.

Why ±20%?

Payer and hospital MRF files are independently produced. Differences arise from rounding, per-day vs per-case structures, and reporting methodology variations. The 20% tolerance (10% above $15K) accounts for these structural differences while requiring fundamental agreement.

Symmetry

Both directions are checked independently. A payer rate gets score 7 if it matches a hospital rate, AND a hospital rate gets score 7 if it matches a payer rate. Both validated rates compete in the final selection.