Federal rules now require payers and providers to publish machine-readable pricing data, giving employers more visibility into what healthcare procedures actually cost.
It’s a meaningful step forward, but price data alone does not tell you enough to act on confidently.
What We’ve Learned from the Data
Providers Who Do Something Often, Do It Better
Claims data tells a consistent story: physicians who perform a specific procedure frequently tend to produce stronger outcomes than those who perform it occasionally.
Volume and quality are connected.
A specialist performing a procedure hundreds of times a year has a track record the data can confirm.
That track record matters for your employees. Sending a member to the lowest-cost option is not the same as sending them to the right one.
Expensive Does Not Mean Better
In many markets, there is little relationship between what a provider charges and how well they perform.
When you layer claims-based quality metrics on top of real negotiated rates, higher-quality providers often come in at lower cost.
The assumption that premium pricing reflects premium care is not something the data consistently supports.
Ghost Rates Make the Problem Worse
Even when employers go looking for answers inside transparency files, the data itself can send them in the wrong direction.
A large share of published rates in these files are what researchers call ghost rates, meaning they have no actual claims history behind them. There’s no evidence that any patient ever received that service at that price from that provider.
A 2025 analysis published in Health Affairs Scholar examined transparency files from 61 insurers and found that nearly 92% of those files contained ghost rates.
For employers trying to use this data to make plan decisions, that kind of noise makes meaningful comparison very difficult without claims-based volume data to filter it out.
What You Can Do With This Information
For employers with 100 or more employees, this opens up a practical opportunity. You may not need a new network or a full RFP process to find more value in your plan. A lot of it may already exist inside your current PPO contracts.
The question is whether you have the right tools in place to cut through misleading rates, cross-reference quality data, and guide employees toward providers who actually perform well on the specific procedures they need.
When that guidance is in place:
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Employees are directed to providers with stronger outcomes for their specific procedure, not just lower sticker prices
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Plan costs become more predictable because decisions are grounded in real claims data
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Your HR team spends less time fielding benefits questions because employees have clear guidance from the start
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You gain a more accurate picture of where plan dollars are actually going
That connection between quality guidance and plan performance is where you’ll see the best results.
Aiming for better guidance
Conversations used to center on whether something was cheap or expensive.
A more useful question now is which providers, for which procedures, in which markets, under your specific plan design, offer the best combination of outcomes and cost.
That answer requires more than a spreadsheet of published rates. You’ll need quality benchmarking, volume analysis, and a clear view of what your plan pays for.
JDI Group helps South Florida employers see inside their health plan using tools like Gradient AI and our Predictability Analysis Report. Send us a DM to learn more.
