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Overview

This enrichment takes the base rate data and adds corresponding Medicare benchmark rates from two primary sources:
  • Medicare RBRVS (Resource-Based Relative Value Scale) rates by locality
  • Medicare ASP (Average Sales Price) rates for applicable codes
The process creates locality-specific and national benchmark comparisons to enable comprehensive rate analysis.

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Data Sources

Medicare RBRVS

Source: CMS Medicare Physician Fee Schedule
Coverage: Professional services with RVU components
Locality: Geographic adjustment factors applied
Currency: 2025 fee schedule rates

Medicare ASP

Source: CMS Average Sales Price files
Coverage: Drug and biologics pricing
Update: January 2025 pricing
Scope: National rates (no locality adjustment)

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Output Schema

The enrichment produces 8 additional columns that are joined to the base rate data:
FieldDescriptionExample
billing_codeProcedure or service code for benchmark matching”99213”, “J0696”
benchmark_nameHuman-readable benchmark source identifier”2025 Dallas MCR (CARRIER 0112026)“
benchmark_typeMedicare benchmark methodology used”MCR_RBRVS”, “MCR_ASP”
benchmark_rateLocality-adjusted Medicare benchmark rate98.75
national_benchmark_nameNational benchmark source identifier”2025 [National] MCR (CARRIER 00000:00)“
national_benchmark_typeNational benchmark methodology”MCR_RBRVS”, “MCR_ASP”
national_benchmark_rateNational Medicare rate without locality adjustment95.50

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Processing Logic

This enrichment helps put commercial insurance rates in context by comparing them to what Medicare would pay for the same services. Smart Benchmark Selection
For doctor visits and medical procedures, the system uses Medicare’s physician fee schedule, adjusting the rates based on local practice costs (since medical expenses vary by geographic region). For prescription drugs and biologics, it uses Medicare’s drug pricing methodology. Apples-to-Apples Comparisons
The system carefully matches billing codes between commercial rates and Medicare fee schedules to ensure fair comparisons. It focuses on standard procedures without special modifiers to create the cleanest possible benchmark relationships, using the most current Medicare rates available.