Report libraryTexas Payer Rate Report
Review the Texas report and watch the video walkthrough to understand the findings and their limitations.
Data period: 2026-Q3
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Texas Payer Rate Report Video Walkthrough
What to look for in the findings
Start with the statewide comparisons, then examine the codes and regional peers relevant to your practice. These findings describe payer-published rates—not verified claim payments.
Payer differences persist within the same practice
The independent-group E/M and well-visit composite is 83% of Medicare at Aetna, 92% at Cigna, and 94% at both BCBS of Texas and UnitedHealthcare. Across 848 independent groups with 99213 rates from at least two payers, the median spread between the highest and lowest published rate is 25% ($17.05).
Compare your market and practice segment—not just the state average
System-employed groups’ median 99213 rates exceed independent medians by 6% at Aetna, 9% at BCBS of Texas, 20% at Cigna, and 29% at UnitedHealthcare. Regional variation can be as large as, or larger than, differences between payers. After counting one multi-market organization once, a consistent large-practice premium remains only at Cigna.
Review vaccine administration and product rates separately
Independent-group median rates for vaccine administration code 90460 range from $10.00 at Aetna to $22.73 at Cigna. For HPV vaccine code 90651, BCBS of Texas publishes a median of $206.38 against the study’s $312.44 reference cost. The report flags that published rate for verification: check your own remittances and acquisition costs before treating it as your payment or margin.
Source: Executive summary and recommendations, pages 7–9; BCBS of Texas data notes, pages 10 and 69. Use the full report for code-level tables, peer counts, and context.
Sources, methodology, and limitations
Sources and study population
PMI used PayerIntel Texas extracts of Aetna, BCBS of Texas, Cigna, and UnitedHealthcare price-transparency files ingested in Q3 2026: 40 files, 3,883,767 rate rows, and 92 pediatric CPT codes. Reference inputs are the 2026 Medicare Physician Fee Schedule and a vaccine-cost reference dated September 22, 2026. No PMI client contracts, billing records, or claims enter the study.
The study includes 1,093 independent groups and 36 system-employed groups. Qualifying general pediatricians are identified by the report’s taxonomy rules; advanced practice providers do not enter peer medians. Independent groups must meet the general-pediatric share test; system groups are shown separately and require at least four pediatricians. Staffing, FQHC/safety-net, urgent-care, subspecialty/complex-care, out-of-state, and unresolved entities are excluded.
How rates and comparisons are calculated
When a payer lists multiple rates for a pediatrician and code, the selection rule prioritizes fee-schedule rows, then office place of service, then the broadest plan bundle, then the upper-median of remaining rates. A group rate is the median of qualifying pediatricians’ representative rates; organization-only listings use the organization row. Statewide summaries use the median across groups, with 25th–75th percentiles and group counts.
Medicare comparisons use national 2026 non-facility amounts without geographic adjustment. The E/M and well-visit composite equally weights six codes: 99213, 99214, 99392, 99393, 99391, and 99381. The headline basket sums medians across ten codes without practice-volume weighting. Groups are assigned to the region containing the largest share of their pediatricians; multi-region groups remain in that region and are flagged.
Statistics based on fewer than three groups are suppressed; those based on three to seven are flagged as thin and should be treated as indicative. Solo duplicates are removed under the study’s rules; larger groups are not deduplicated.
What these results can—and cannot—tell you
A published rate is not necessarily the amount paid on a claim. Plan product, place of service, modifiers, and benefit design can affect actual payment. The study does not evaluate contract terms, collections, or a practice’s actual service volume. Its reference visit-mix illustrations are modeled comparisons, not measured practice revenue, forecasts, or guaranteed improvement.
Vaccine reference costs are base-tier member costs from a large buying group, net of discounts, rebate, and tax. Comparisons use the highest-cost brand when a code has multiple brands; your practice’s acquisition costs may differ. Statewide results are not a substitute for a practice-specific market comparison or verification against remittances.
Important payer-file caveats
- Aetna: Multiple rates can appear for the same pediatrician and code. Results use the fee-schedule-first selection rule, not the highest listed rate; a different rule can change comparisons.
- BCBS of Texas export coverage: A supplemental Q3 2026 re-export replaces earlier rows for 96127, 96160, 96161, 99173, and 99177 after the original export hit a row limit.
- BCBS of Texas 90651: The near-uniform published $206.38 rate is reported as supplied. Confirm it against your own remittances before treating it as your payment rate.
- BCBS of Texas 99174: Coverage may be incomplete; only 67.5% of included BCBS groups have a published rate for this code.