Public Data
Medicare Reference Pricing
Understand commercial health insurance payments across Colorado as a percent of Medicare payments.
Many cost reduction strategies have been implemented and tested to address rising health care costs both locally and nationally. One strategy in particular – negotiating rates using Medicare payments as a reference – has proven effective in reducing health care spending, especially for large employers.
This analysis shows commercial health insurance payments for facilities (including hospitals and free standing ambulatory surgical centers) for inpatient (IP) and outpatient (OP) services as a percent of Medicare, along with geographic comparisons and percent change from 2021.
Considerations
Differences between April 2025 and Nov 2025 Medicare Reference Based-Pricing for 2023 claims
- CIVHC uses claims data repriced with the Milliman Medicare Repricer software for figures reported in the annual Medicare Reference Based Price (RBP) Analysis. Misclassifications were identified in Milliman’s application of 2023 Medicare fee schedules, specifically for claims occurring at critical access hospitals (CAHs) and ambulatory surgical centers (ASCs), which lead to incorrect repricing.
- Upon identifying the issues with the Milliman Medicare Repricer data from 2023, CIVHC developed, in collaboration with Milliman, a corrective methodology to ensure accurate reporting in the CO APCP Medicare Reference-Based Pricing dashboard published in April 2025. CIVHC’s corrective methodology used a formula with HCPCS procedure codes to determine outpatient Medicare pricing, and MS-DRGs for inpatient pricing. Considering that 2022 claims were correctly processed, the median repriced amounts from 2022 (categorized by HCPCS or MS-DRG code) were used as reference points to approximate 2023 repriced values. The actual allowed amount for 2023 was then divided by the estimated Medicare-allowed amount to generate a corrected percentage of Medicare pricing.
- The current Medicare Reference-Based Pricing dashboard, published in November 2025, utilizes an updated version of Milliman’s Medicare Repricing software which reflects accurate classifications of claims, thus eliminating the need to use a corrective methodology. The report incorporates correctly applied Medicare fee schedules for all years and claim types.
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Use Cases
Comparing percent Medicare information across facilities can help consumers understand how payments vary for health care services. Our Shop for Care tool can also be used to see procedure specific prices.
Use the data to see how your prices compare and to negotiate rates based on what Medicare would pay for services. Peak Health Alliance uses Medicare reference-based price data with hospitals and has achieved lower premiums as a result.
Use this information to understand how your payments compare to Medicare and to your peers, and to find referral options.
Use this information to understand payment variation and identify ways to make health care more affordable.
Use this information to understand payment variation and identify ways to make health care more affordable and high value.
Study price variation between hospitals and facilities and year over year changes.