On January 13 2023, UnitedHealthcare filed a protest with the State of North Carolina stating that Aetna was unjustly awarded the third party administrative services for the State's teacher and state employees health plan. United's claim was that they were not given credit for having lower costs than Aetna. If they were properly recognized for having lower costs, they would have won the contract.
Price Transparency data takes a central role in United's argument. The health plan used data from publicly posted machine readable files to show that their prices in North Carolina were consistently 6% to 7% lower than Aetna's across providers, regions and billing codes.
The complete protest letter can be accessed here.
In addition to analyzing Coordination of Benefits (COB) and Uniform Data Submission (UDS) data, United Healthcare used Transparency in Cost data to compare their contractual rates to those of Aetna. United stated: "This analysis utilized publicly available, accurate, and current payer reimbursements, and provides incontrovertible evidence that Aetna is at a significant and material cost disadvantage to UnitedHealthcare in the North Carolina market."
The analysis supporting United Healthcare's claims is detailed in Exhibit 2 of the protest letter. It calculated a Network Efficiency Factor (NEF) which is United Healthcare's contractual rate divided by the competitor's rate. The NEF was calculated for 8 top North Carolina Providers and Physician Groups. The summary was presented in the table below:
Each Provider was further analyzed at the procedure-specific level to demonstrate the NEF by Inpatient services, Surgical services (by Grouper), Emergency, Diagnostics, and Other Outpatient services. As an example, Duke University Medical Center's procedure analysis is presented below:
Medlyze support health plans to proactively access Price Transparency data for competitor health plans, structure analysis and support teams to competitively position in markets. Our aim is to support growth and profitability of our clients.