Estimated Commercial Prices and Savings

Commercial price estimates on Care Connect use a pricing algorithm that integrates data from various sources. The algorithm combines payments from all participants and fees in each bundle to enable accurate comparison between Care Connect’s all-inclusive prices and typical fee-for-service insurance payments.

These sources are used in Care Connect commercial prices:

• Commercial benchmarks derived from 2024 Payer Transparency in Coverage datasets are mapped and aggregated to Tendo Marketplace procedure bundles, and adjusted using claims data for a complete episode of care. If sufficient data is not available, the estimated commercial prices are not displayed.
• Medicare rates are based on national payment schedules - IPPS (inpatient), OPPS (outpatient), and ASC (ambulatory surgery centers) set by the Centers for Medicare & Medicaid Services (CMS). Tendo maps the CMS rates to Tendo Marketplace procedure bundles and adjusts to represent complete episodes of care. Physician services use the local Medicare Administrative Contractor (MAC) value from the Medicare Physician Fee Schedule (PFS) when it’s available. This value is a specific dollar amount for a given medical service in a particular geographic area.

When both ASC and OPPS data exist for a procedure in a given region, rates for hospitals and ASCs are blended for both commercial benchmarks and Medicare rates with outpatient hospital rates given a higher weight to reflect the behavior of patients not working with a care navigator.

Commercial and CMS rates can differ from other sources due to several factors, including:

• The specific payer data available to Tendo
• Mapping, weighting, and aggregation to Tendo Marketplace bundles
• Adjustments based on comparisons to commercial and Medicare claims to capture complete episodes of care
• Blending of hospital and ASC prices when both are available for the procedure
• Use of national (non-locality adjusted) CMS fee schedule rates for facilities

The percentage of CMS for Tendo Marketplace offers displayed in this context may differ from the CMS percentage used when providers set pricing due to the factors above and the fact that Tendo Marketplace offers include Tendo’s fee.

You may notice that there can be a difference in estimated prices on Care Connect and MDsave. This is because the estimated prices on Care Connect are intended to show typical payments by commercial insurance providers for a procedure. The estimates on MDsave incorporate self- and cash-pay prices in addition to contracted commercial rates to reflect typical payments by cash pay consumers purchasing a procedure.

You also may notice that in some cases, providers' prices are above the comparable commercial average. This is because providers are allowed to set their own prices, and not every provider's prices are lower than the commercial average even when they provide a discount for listings on Tendo Marketplace. The commercial average on procedures is not relative to the specific provider but to a local average, and providers' prices at some facilities are more expensive than their local market.

In some cases, providers also have higher prices for office visits relative to surgical procedures. For example, a physician may list orthopedic new patient office visits for above the commercial average for the market, but the physician's surgical procedures are listed at a discount that is less than the commercial average.

If you have questions or feedback about any specific prices displayed, please let us know.