Version: 3.0

v2_4_1

Generated: 2026-03-11 19:29:45

Overview

This analysis examines the accuracy of canonical rates by analyzing scoring patterns and identifying potential outliers based on Medicare rate comparisons.

1. Outlier Score Analysis

Records with Outlier Canonical Rate Score

Total Records with canonical_rate_score = 1 (outliers): 134,778,600

Click to see SQL

            SELECT COUNT(*) as outlier_score_count
            FROM tq_dev.internal_dev_csong_cld_v2_4_1.prod_combined_all
            WHERE canonical_rate_score = 1
            

2. cbsa Medicare Rate Outliers

Rates vs cbsa Medicare Rates

Total Rates: 818,743,507 records

provider_type	bill_type	count	below_80pct_count	above_15x_count
Physician Group	Professional	385,277,188	65,474,613	0
Hospital	Outpatient	310,449,245	27,354,001	5,244,866
Hospital	Inpatient	75,586,993	0	0
ASC	Outpatient	28,351,977	4,148,303	516,581
Laboratory	Professional	14,431,178	7,623,193	0
Imaging Center	Professional	4,646,926	564,238	2,872

Click to see SQL

            SELECT
                provider_type,
                bill_type,
                COUNT(*) as count,
                COUNT(CASE WHEN canonical_rate < 0.8 * cbsa_avg_medicare_rate THEN 1 END) as below_80pct_count,
                COUNT(CASE WHEN canonical_rate > 15 * cbsa_avg_medicare_rate THEN 1 END) as above_15x_count
            FROM tq_dev.internal_dev_csong_cld_v2_4_1.prod_combined_all
            WHERE canonical_rate_score > 1
            GROUP BY provider_type, bill_type
            ORDER BY count DESC
            

3. Medicare Rate Outliers

Rates vs Facility-Specific Medicare Rates

Total Rates: 818,743,507 records

provider_type	bill_type	count	below_80pct_count	above_15x_count
Physician Group	Professional	385,277,188	65,474,613	0
Hospital	Outpatient	310,449,245	27,197,182	5,271,341
Hospital	Inpatient	75,586,993	604,114	9,401
ASC	Outpatient	28,351,977	3,961,083	633,516
Laboratory	Professional	14,431,178	7,623,193	0
Imaging Center	Professional	4,646,926	564,238	2,872

Click to see SQL

            SELECT
                provider_type,
                bill_type,
                COUNT(*) as count,
                COUNT(CASE WHEN canonical_rate < 0.8 * medicare_rate THEN 1 END) as below_80pct_count,
                COUNT(CASE WHEN canonical_rate > 15 * medicare_rate THEN 1 END) as above_15x_count
            FROM tq_dev.internal_dev_csong_cld_v2_4_1.prod_combined_all
            WHERE canonical_rate_score > 1
            GROUP BY provider_type, bill_type
            ORDER BY count DESC
            

4. Canonical Rate Score Distribution

Distribution of Canonical Rate Scores

canonical_rate_score	record_count	percentage
0	4,711,732,935	83.0%
1	134,778,600	2.0%
2	103,133,853	2.0%
3	427,326,877	8.0%
4	242,920,152	4.0%
5	45,362,625	1.0%

Click to see SQL

            SELECT
                canonical_rate_score,
                COUNT(*) as record_count,
                ROUND(1.000 * COUNT(*) / SUM(COUNT(*)) OVER(), 2) as percentage
            FROM tq_dev.internal_dev_csong_cld_v2_4_1.prod_combined_all
            GROUP BY canonical_rate_score
            ORDER BY canonical_rate_score
            

4.1. Canonical Rate Score Distribution by Provider Type

Distribution of Canonical Rate Scores by Provider Type

provider_type	canonical_rate_score	record_count	percentage
ASC	0	216,587,199	87.0%
ASC	1	4,228,181	2.0%
ASC	2	174,958	0.0%
ASC	3	248,653	0.0%
ASC	4	27,928,366	11.0%
Hospital	0	1,567,792,793	77.0%
Hospital	1	71,745,703	4.0%
Hospital	2	28,520,037	1.0%
Hospital	3	113,246,429	6.0%
Hospital	4	205,868,886	10.0%
Hospital	5	38,400,886	2.0%
Imaging Center	0	62,956,539	93.0%
Imaging Center	1	188,630	0.0%
Imaging Center	2	77	0.0%
Imaging Center	3	268	0.0%
Imaging Center	4	4,646,581	7.0%
Laboratory	0	106,193,905	88.0%
Laboratory	1	533,093	0.0%
Laboratory	2	1,825,682	2.0%
Laboratory	3	5,199,686	4.0%
Laboratory	4	796,466	1.0%
Laboratory	5	6,609,344	5.0%
Physician Group	0	2,758,202,499	86.0%
Physician Group	1	58,082,993	2.0%
Physician Group	2	72,613,099	2.0%
Physician Group	3	308,631,841	10.0%
Physician Group	4	3,679,853	0.0%
Physician Group	5	352,395	0.0%

Click to see SQL

            SELECT
                provider_type,
                canonical_rate_score,
                COUNT(*) as record_count,
                ROUND(1.000 * COUNT(*) / SUM(COUNT(*)) OVER(PARTITION BY provider_type), 2) as percentage
            FROM tq_dev.internal_dev_csong_cld_v2_4_1.prod_combined_all
            GROUP BY provider_type, canonical_rate_score
            ORDER BY provider_type, canonical_rate_score
            

5. Extreme Rate Ratios by Code Combination

Code Combinations with Most Rates < 0.2x Medicare

Top 20 provider_type, bill_type, billing_code combinations with the most rates below 20% of Medicare rates:

provider_type	bill_type	billing_code	total_records	below_20pct_count	below_20pct_percentage
Hospital	Inpatient	795	46,295	197	0.0%
Hospital	Inpatient	807	48,829	72	0.0%
Hospital	Inpatient	310	51,266	72	0.0%
Hospital	Inpatient	298	33,405	72	0.0%
Hospital	Inpatient	601	43,457	70	0.0%
Hospital	Inpatient	395	47,641	67	0.0%
Hospital	Inpatient	285	36,379	66	0.0%
Hospital	Inpatient	195	49,290	64	0.0%
Hospital	Inpatient	730	38,401	64	0.0%
Hospital	Inpatient	833	43,753	64	0.0%
Hospital	Inpatient	0640-1	45,317	63	0.0%
Hospital	Inpatient	759	45,490	62	0.0%
Hospital	Inpatient	684	48,739	62	0.0%
Hospital	Inpatient	761	44,556	61	0.0%
Hospital	Inpatient	387	48,235	60	0.0%
Hospital	Inpatient	639	48,936	60	0.0%
Hospital	Inpatient	816	45,564	60	0.0%
Hospital	Inpatient	806	48,116	60	0.0%
Hospital	Inpatient	700	46,841	59	0.0%
Hospital	Inpatient	316	46,291	58	0.0%

Click to see SQL

            SELECT
                provider_type,
                bill_type,
                billing_code,
                COUNT(*) as total_records,
                COUNT(CASE WHEN canonical_rate < 0.2 * medicare_rate THEN 1 END) as below_20pct_count,
                ROUND(1.000 * COUNT(CASE WHEN canonical_rate < 0.2 * medicare_rate THEN 1 END) / COUNT(*), 2) as below_20pct_percentage
            FROM tq_dev.internal_dev_csong_cld_v2_4_1.prod_combined_all
            WHERE canonical_rate_score > 1
                AND medicare_rate IS NOT NULL
                AND medicare_rate > 0
            GROUP BY provider_type, bill_type, billing_code
            HAVING COUNT(CASE WHEN canonical_rate < 0.2 * medicare_rate THEN 1 END) > 0
            ORDER BY below_20pct_count DESC, below_20pct_percentage DESC
            LIMIT 20
            

Code Combinations with Most Rates > 10x Medicare

Top 20 provider_type, bill_type, billing_code combinations with the most rates above 10x Medicare rates:

provider_type	bill_type	billing_code	total_records	above_10x_count	above_10x_percentage
Hospital	Outpatient	72125	62,412	27,224	44.0%
Hospital	Outpatient	72131	62,342	26,512	43.0%
Hospital	Outpatient	71250	62,789	26,105	42.0%
Hospital	Outpatient	37182	51,026	25,963	51.0%
Hospital	Outpatient	72128	61,771	25,862	42.0%
Hospital	Outpatient	70486	62,605	25,453	41.0%
Hospital	Outpatient	62284	51,061	25,289	50.0%
Hospital	Outpatient	31627	36,894	25,165	68.0%
Hospital	Outpatient	70450	62,790	25,134	40.0%
Hospital	Outpatient	74150	61,366	24,780	40.0%
Hospital	Outpatient	70480	61,532	24,741	40.0%
Hospital	Outpatient	72192	61,652	24,704	40.0%
Hospital	Outpatient	76390	52,089	24,507	47.0%
Hospital	Outpatient	73700	60,923	24,436	40.0%
Hospital	Outpatient	73200	60,658	24,347	40.0%
Hospital	Outpatient	70490	60,606	23,553	39.0%
Hospital	Outpatient	29826	36,142	22,576	62.0%
Hospital	Outpatient	71275	62,085	22,552	36.0%
Hospital	Outpatient	76942	52,665	21,993	42.0%
Hospital	Outpatient	70496	62,240	21,780	35.0%

Click to see SQL

            SELECT
                provider_type,
                bill_type,
                billing_code,
                COUNT(*) as total_records,
                COUNT(CASE WHEN canonical_rate > 10 * medicare_rate THEN 1 END) as above_10x_count,
                ROUND(1.000 * COUNT(CASE WHEN canonical_rate > 10 * medicare_rate THEN 1 END) / COUNT(*), 2) as above_10x_percentage
            FROM tq_dev.internal_dev_csong_cld_v2_4_1.prod_combined_all
            WHERE canonical_rate_score > 1
                AND medicare_rate IS NOT NULL
                AND medicare_rate > 0
            GROUP BY provider_type, bill_type, billing_code
            HAVING COUNT(CASE WHEN canonical_rate > 10 * medicare_rate THEN 1 END) > 0
            ORDER BY above_10x_count DESC, above_10x_percentage DESC
            LIMIT 20
            

Overview​

1. Outlier Score Analysis​

Records with Outlier Canonical Rate Score​

2. cbsa Medicare Rate Outliers​

Rates vs cbsa Medicare Rates​

3. Medicare Rate Outliers​

Rates vs Facility-Specific Medicare Rates​

4. Canonical Rate Score Distribution​

Distribution of Canonical Rate Scores​

4.1. Canonical Rate Score Distribution by Provider Type​

Distribution of Canonical Rate Scores by Provider Type​

5. Extreme Rate Ratios by Code Combination​

Code Combinations with Most Rates < 0.2x Medicare​

Code Combinations with Most Rates > 10x Medicare​

On this page:

Overview

1. Outlier Score Analysis

Records with Outlier Canonical Rate Score

2. cbsa Medicare Rate Outliers

Rates vs cbsa Medicare Rates

3. Medicare Rate Outliers

Rates vs Facility-Specific Medicare Rates

4. Canonical Rate Score Distribution

Distribution of Canonical Rate Scores

4.1. Canonical Rate Score Distribution by Provider Type

Distribution of Canonical Rate Scores by Provider Type

5. Extreme Rate Ratios by Code Combination

Code Combinations with Most Rates < 0.2x Medicare

Code Combinations with Most Rates > 10x Medicare