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About Healthcare Pricing Information


The VHI Healthcare Pricing Report was created under Virginia law 32.1-276.5:1 to increase healthcare transparency in Virginia. The healthcare services in this report are those provided by doctors, emergency rooms, hospitals, diagnostic and surgical centers.

The services reported were recommended to Virginia Health Information (VHI) by a workgroup of healthcare stakeholders. After VHI Board of Directors review, the list of services was approved by the State Health Commissioner. Commercial insurance allowed amounts are based on 2016 paid commercial claims within the Virginia All Payer Claims Database and exclude government programs like Medicare and Medicaid.

Virginia Health Information (VHI) is an independent non-profit organization. VHI works under contracts with state agencies and others to provide consumers with information on healthcare cost and quality.

General Overview of Methodology

  1. Claims are paid by health insurance carriers for the service billed by health care providers. These claims include the type of service performed and the allowed amount for each service
  2. Paid claims are submitted by health insurance carriers to the Virginia APCD which are then edited, combined and aggregated by VHI
  3. VHI selects claims from the Virginia APCD related to each Healthcare Pricing Transparency service based on the information that defines each service
  4. VHI follows the methodology jointly developed with health providers and health insurance carriers to calculate the average allowed amount for each service
  5. VHI then calculates average allowed amount per service by patient region and the type of location the service was performed in
  6. The multiple types of allowed amounts a patient may encounter for a given service are calculated and broken out within the final report
Throughout this process VHI validates data quality, removes excessively high and low values and ensures that, consistent with Virginia law, payer and provider specific amounts are not disclosed.

Limitations

Because insurance plans may have different benefits, our report does not show you exactly what you will pay. This information may be available from your insurance carrier. A link to price transparency tools available through individual health insurance carriers is provided within each pricing report for more information.

  • Consumers without insurance coverage may not get as much of a discount as a larger health insurance carrier.
  • The average allowed amount of a service for some geographic areas within a Virginia Health Planning Region may vary.
  • Some health insurance carriers may negotiate lower allowed amounts than others. State averages do not show the lowest allowed amount. In some cases, price variations between carriers were high. Not every individual experienced every potential type of cost for a given service. It’s important to note that individual costs may be much lower or higher depending on the types of services included.
  • All average allowed amounts are displayed as an unweighted average across all health plans to protect individual proprietary reimbursement rates. Unweighted averages will vary from traditional weighted averages in that a health plan’s market share within a given area has no impact on the proportion of the average rate that they represent.
  • For actual allowed amounts to be reported for a particular service, region and location paid claims representing at least 3 payers and providers had to be included.
  • The Ambulatory Surgery Center setting was removed from the Arthrocentesis report due to the small amount data available on these procedures.
  • In addition to the standardized outlier removal process outlined in the Health Pricing Report methodology document, some additional extreme outliers were removed from the analysis on a case by case basis