Provider Ranking System (PRS) is designed for use by self-insured employers and health insurance companies to manage networks of providers, and to ensure that their employees or clients have access to the best doctors and other providers. It is also used by case managers and treating doctors to ensure they provide the best medical referrals by researching doctor ranking. In addition, it is utilized by pharmaceutical and medical device companies to identify providers who would be interested in their products.
PRS is a B2B (business to business) SaaS (Software as a Service) designed for use by professionals. It is not designed as a consumer service for use by patients, but selected information is available on a Complimentary Consumer Portal for free public use at https://www.providerrankings.com. Patient-Doctor finder services are supported by advertising, and this advertising influences how different providers appear. Provider Ranking System by Denniston Data provides actual experience data on every provider in the U.S., and it does not accept advertising or payment for listings.
The entry point to PRS is either by provider or by medical procedure. In addition, you can look up medical specialties with rankings by Composite Ranking Score (explained below). Over one million providers are covered per year, including medical doctors and all other types of providers that bill for medical procedures. You can lookup providers by 10-digit NPI (National Provider Identifier) number, or by any combination of last name, first name, city, state, and medical specialty. Any of these will narrow your search and give you a list of providers, so you can select the appropriate “Provider Page” by NPI.
The other way to start is to begin with a medical procedure. You can access medical procedures either with the appropriate 5-character HCPCS (Healthcare Common Procedure Coding System) medical procedure code, i.e., 93656, or by searching on any words used in the procedure code description, like “catheter,” “ablation,” “atrial.” Any keyword will narrow your search and give you a list of procedures and services, enabling you to select the appropriate “Ranking Page,” which identifies the providers performing that procedure in ranked order among their peers. If you are unsure about which medical procedure, a helpful technique is to look up a provider first, who you know is doing the procedure of interest, and view their top procedures. Then you can click on their ranking of that procedure to see who their competitors are.
Once you reach a “Provider Detail” page that you are searching for, you will see general information on the size of the practice for the latest year, in dollars approved and paid, in dollars billed, in number of patients, in number of different procedures performed, and in total procedures. The ratio of billed amount to approved amount is shown, indicating potential increased costs for some providers. Data is available from 2012 through the most current year, so you can look at every piece of the data for any year. Data trends by year are illustrated through line charts, which show the direction the practice is going. Is it growing rapidly or declining?
Information is also supplied on the demographics of the patients seen by the provider. This includes age, gender, and race. It also includes the most common conditions for the provider’s patients.
An average risk score is given, indicating the relative risk of the provider’s patients. When considering outcomes, this can be important. The risk score is explained in more detail below.
The new Provider Background Section includes medical school information and year of graduation, group practice and hospital affiliations, and the CMS MIPS (Merit-based Incentive Payment System) score. The MPIS score is explained in more detail below.
The most important information is what the provider actually does, and how that provider ranks compared to his or her peers, both nationally, and within their own geographic area. The doctor ranking in each Provider Detail is based on total dollars approved, so that the procedures which are most important to that provider’s practice are listed first.
In addition to dollars billed and dollars approved, the list includes number of services and what percent were repeats performed on the same patient. This repeat rate may indicate that the provider had to redo a procedure that was not successful the first time, or it may indicate the procedure needed to be done on a regular basis.
Along with each HCPCS code and description, general location is given. Location identifies whether the place of service is a facility or non-facility. Non-facility is generally an office setting. The allowed reimbursement for a provider is very different (less) for the same procedure when performed in a facility, such as a hospital, as there is an additional hospital reimbursement, so each combination of HCPCS code and location are listed separately.
The last two columns for each procedure are key. The first one identifies where the provider ranks on a national basis among all providers in the U.S. who have done this procedure at least 11 times in that year. If the doctor ranking is in the top quarter of all providers, then the cell is highlighted in green. If the doctor ranking is in the top half, but not in the top quarter, it is highlighted in yellow. To identify which providers ranked higher than this provider, you can click on the ranking and it will open a new page, the “Procedure Ranking” page, ranking all of the providers with respect to how many times they have done this procedure for the specific year being reviewed, as well as compare them to their peers over all eight or more years by viewing graphical trends. With the graphs, you can also see how they rank for all years of data combined.
Likewise, the next column provides the same information for the provider’s regional area, using Zip3, the first 3 digits of the zip code. Zip3 provides a local area that is generally within the distance where people would drive to a local provider.
When “eye-balling” a provider’s list of procedures, the appearance of green cells toward the top is a very good sign, showing that this provider is in the top 25% of his or her peers for those services that are most important to their practice. The appearance of yellow cells indicates they are in the top half.
The “Ranking Page” is available on a national basis, and on just a local area, using Zip3. Within every ranking page, the “list price,” what each provider bills on average for that procedure, is shown along with the average approved amount in dollars. This information may be important if the provider is used out of network. This pricing information may be especially helpful with the implementation of the No Surprises Act, and the requirement in Section 114 for health plans to maintain online price comparison tools that will allow patients to compare expected out-of-pocket costs for items and services across multiple providers.
The updated Procedure Ranking Section now indicates medical specialty, so you can distinguish between, for example, Orthopedic Surgery vs Sports Medicine, Physical Therapists vs. Chiropractors, who may perform the same service. The table Filter function allows restricting the ranking to only one specialty. Lastly, the Specialty Ranking table now provides street addresses. A user can select providers by street using the Filter function to limit them to a group and, within the group, they can see the ranking of each provider in the practice, plus patient risk score & MIPS.
Using DataTables™ Software, all of the ranking tables are dynamic databases. Every column is sortable, so you can see which doctor has the highest or lowest average list price compared to approved amount, or the lowest or highest repeat rate for surgeries. The entire table can be filtered by anything, street address, state code, specialty, and you can control how much of the table you see. Eventually, the data tables can be downloaded as pdf files or csv files (to be imported into a spreadsheet program like Excel, or a database for AI).
Finally, the local rankings within a Zip3 area, for both the Procedure Ranking (rank by number of procedures performed and approved per year by provider) and the Specialty Ranking (rank by overall Composite Ranking Score for every provider within a medical specialty), can be broadened to a larger geographic area using Zip2. Just drop the last digit on the Zip3 code, and click on “Load Detail.” If the list of doctors in a Zip3 area are not sufficient, or they are not high performing nationally, you can expand the area until you find what you want.
Average Risk Score of Patients
While the data are not risk adjusted and thus do not account for difference in the underlying severity of disease of patient populations treated by providers, we have provided average beneficiary risk scores to provide information on the health status of the beneficiaries the providers serve, so different providers can be compared. The data presented are summarized from actual claims received from providers and no attempts were made to modify any data.
Those scores estimate how beneficiaries’ spending will compare to the overall average for the entire Medicare population. The average risk scores of beneficiaries represented in each calendar year are provided in the table below. Beneficiaries with scores greater than the average risk score are expected to have above-average spending, and vice versa. Risk scores are based on a beneficiary’s age and sex; whether the beneficiary is eligible for Medicaid, first qualified for Medicare on the basis of disability, or lives in an institution (usually a nursing home); and the beneficiary’s diagnoses from the previous year.
For more information see here: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors
Composite Ranking Score (CRS) & Overall Grade
The Composite Ranking Score (CRS) is the weighted average percentile score for all procedure rankings for this provider, 0 to 100%. The score is calculated first for each procedure listed on the Provider Ranking by HCPCS table, where, for example, 100% means no providers ranked higher, 92% means 8% ranked higher, and 45% means 55% ranked higher. Then these scores are averaged for all the procedures listed for a medical provider on the Provider Ranking by HCPCS table, after weighting by approved dollars for that provider, in order to give weight to the procedures that are most significant for that provider. Then, to calculate the Ranking of CRS by Medical Specialty, the CRS percentile is ranked for all providers indicating the same medical specialty. The CRS may be displayed as a rounded percentile, but when ranking, the actual score is used, which is accurate to 4 digits.
Grade A+ is CRS>95, A is CRS>85, A- is CRS>80, B+ is CRS>75, B is CRS>65, B- is CRS>60, C+ is CRS> 55, C is CRS>45, C- is CRS>40, D+ is CRS>35, D is CRS>25, D- is CRS> 20, and F is the rest.
Merit-based Incentive Payment System (MIPS)
The Merit-based Incentive Payment System (MIPS) Score (ranging from 0-100 points), is based on process measures for quality, communication (interoperability), cost, and improvement activities; the score is used by CMS to adjust reimbursement to a provider, with a score under 30 in 2019 resulting in up to 7% lower payment in 2021, and a score over 75 resulting in up to 7% higher payment. The quality score includes measures suggesting adherence to evidence-based medical treatment guidelines.
Note About Dates and Currency of the Data
CMS is on a fiscal year basis, from October 1 through September 30. So the data labelled 2021 is Fiscal Year 2021, Oct. 1, 2021 – Sep. 30, 2022. This data was available in May of 2023, and it covered claims through September of the previous year, so it was seven months old when it was first presented in the PRS format with the PRS tools. For more information see here.
Click for sample screenshots.
See also the Source of Data.