Transparency in Coverage Data to Expose Ghost Rates and Hold Payers Accountable: David Muhlestein, PhD

On this episode of Managed Care Cast, The American Journal of Managed Care^® (AJMC^®) spoke with David Muhlestein, PhD, JD, founder and CEO of Simple Healthcare, about his recent articles highlighting Transparency in Coverage (TIC) files and ghost rates from 61 insurers, including 3 national commercial payers. One was published in Population Health, Equity & Outcomes (PHEO; a sister journal of AJMC)¹ and the other was published in Health Affairs Scholar.²

Aetna, Cigna, and United Healthcare’s TIC files were more than 90% ghost rates—billing codes for procedures that would never be performed by a specific physician. For example, there were billing codes for heart surgery performed by a psychiatrist, Muhlestein said. These ghost rates increase the size of TIC files, making them difficult for consumers, researchers, and analysts to evaluate. Data files of this size muddle the true aim of the TIC files: to provide actual transparency that would allow consumers to compare the prices of health care services and choose more affordable options.²

In the PHEO analysis, UnitedHealthcare had limited data on hospital inpatient data, and Cigna had very incomplete hospital outpatient data.¹ Muhlestein also noted that Cigna and United Healthcare were not the only payers with significantly incomplete data. Based on his findings, Muhlestein urges CMS officials to set stricter regulations addressing ghost rates and to take disciplinary action against payers who do not adhere to them.

TIC files are a huge step forward for transparency and holding payers accountable for their services. The next step, which Muhlestein said is already in progress, is obtaining TIC files for prescription drug negotiated rates. Consumers are more likely to utilize these files to gauge the most affordable price for their medications, Muhlestein said.

“We want to have people that are competing in cost and quality.… It's problematic when people don't know what the cost is and they don't know what the quality is,” Muhlestein said. “And price transparency is a big step along that way to help us understand what the price is so that people can start to compete based on price.”

References

1. Muhlestein DB, Pathak Y. Price transparency with gaps: assessing the completeness of payer transparency in coverage data. Am J Manag Care. 2025;31(Spec. No. 15):SP1121-SP1127. doi:10.37765/ajmc.2025.89862

2. Muhlestein DB. High prevalence of ghost rates in transparency in coverage data. Health Aff Sch. 2025;3(11):qxaf212. doi:10.1093/haschl/qxaf212

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