In an era where healthcare transparency is widely promoted yet unevenly delivered, decision-makers must navigate a crowded field of quality measurement tools. Consumer apps highlight patient satisfaction. Digital directories emphasize convenience. Enterprise analytics platforms may focus on narrow slices of outcomes or cost. Each contributes a part of the puzzle, but very few offer a complete and unbiased procedure-level picture of provider quality.
This challenge is particularly acute for self-insured employers, international referral networks, case managers, and medical tourism facilitators. Their decisions directly influence costs, outcomes, and patient safety. They need a tool that moves beyond opinions, marketing visibility, or selective metrics. They require a data-driven solution built on real-world performance.
This is where Denniston Data’s claims-based Provider Ranking System provides a transformative approach. Instead of relying on surveys, self-attestations, or generalized specialty-level ratings, PRS uses the most objective evidence source available. That source is actual claims representing what providers did, for whom they did it, how often they did it, and what the outcomes were.
Why Claims Data Is the Foundation for Objective Provider Rankings
Claims data is the closest available proxy for real-world clinical practice. It reveals what providers actually do rather than what they say they do. It reflects patterns of care across settings, populations, and years. It captures the frequency, type, and sequencing of procedures.
Claims data removes subjectivity because:
1. It is not influenced by self-promotion or marketing.
Providers cannot pay to influence the information. Their billed procedures, intervention patterns, and complication indicators are automatically recorded.
2. It represents all patients, not just vocal subsets.
Unlike satisfaction surveys or review platforms that are driven by extreme experiences, claims data reflects the entire population across payers.
3. It operationalizes clinical experience.
Volume matters. A provider who performs a procedure 150 times a year is operating at a different level than a provider who performs it 10 times. Claims data identifies this difference with precision.
4. It allows comparison across peer groups.
Claims structure enables comparable analyses by procedure, specialty, region, and practice setting.
5. It uncovers patterns that are invisible to survey-based tools.
These patterns include overutilization, unnecessary interventions, complication predictors, and adherence to evidence-based medical necessity.
Claims data provides the only scalable, unbiased, and comprehensive foundation for national provider performance evaluation.
The Limitations of Traditional Quality Tools
Healthcare navigation tools often focus on one or two dimensions of quality. The problem is not what they include. The problem is what they leave out.
Patient Reviews Rarely Reflect Clinical Quality
Reviews are influenced by service factors rather than clinical outcomes. Parking availability, friendliness, wait times, and office appearance often matter more to reviewers than accuracy of diagnosis or avoidance of complications.
Adverse Event Metrics Capture Only Extremes
Mortality, readmissions, and major complications are important, but after risk adjustment they generally identify only the best and worst performers. The majority of providers fall into a middle band where differences become statistically indistinguishable.
Practice Pattern Indicators Are Insightful but Incomplete
Evidence-based medicine rules help determine appropriateness of care, but they do not explain whether providers achieve successful results over time. Strong documentation skills do not necessarily indicate strong clinical skills.
Generalized Specialty-Level Ratings Mislead
A specialist may be excellent at two procedures and only average at ten others. Without procedure-level granularity, navigators cannot make precise referrals.
Price Transparency Alone Does Not Equal Value
Cost must be understood in context. A low-cost provider who performs unnecessary procedures does not represent value. A higher-cost provider with excellent outcomes may create long-term savings.
Most tools measure fragments. Very few measure the whole.
How PRS Integrates Multi-Payer Claims for Holistic Provider Assessment
Denniston Data’s PRS integrates commercial health claims, Medicare Fee-for-Service, Medicare Advantage, and workers’ compensation claims. The data represents more than a decade of longitudinal performance across millions of lives.
The system analyzes more than 2 million unique providers across the United States and evaluates them using several key dimensions.
1. Procedure-Level Volume and Experience
PRS identifies exactly which procedures a provider performs most frequently and how these volumes compare to peer averages. This answers the central clinical navigation question: What is this provider actually best at?
2. Practice Pattern Analysis
Claims reveal deep insights into clinical decision-making. These include:
- Rates of conservative versus aggressive intervention
- Use of imaging, injections, medications, and surgical steps
- Alignment with medical necessity criteria
- Indicators of overutilization or unnecessary escalation
This reveals whether a provider follows medically justified pathways.
3. Outcomes and Adverse Indicators
Claims reveal signals of quality such as:
- Postoperative complications
- Revision surgeries
- Readmissions related to prior procedures
- Emergency visits linked to earlier episodes of care
PRS normalizes these measures by patient risk factors and peer benchmarks to generate accurate comparisons.
4. Cost and Reimbursement Alignment
Through integration with Transparency in Coverage pricing, PRS captures:
- Billable and allowable costs
- Network-specific negotiated rates
- Variations in episode-of-care expenses
This allows buyers and navigators to identify high-quality and cost-efficient providers.
5. Longitudinal Trends Over Multiple Years
Providers change over time. PRS captures:
- Three-year performance trajectories
- Shifts in procedure mix
- Changes in complications or decision-making patterns
This helps stakeholders determine whether a provider is improving, stable, or declining.
Together these components create a complete and evidence-based view of provider performance.
The Composite Ranking Score and Smart Score
PRS provides two core outputs that transform complex analytics into practical decision-making tools.
Composite Ranking Score (CRS)
CRS is a pure quality measure based on:
- Experience
- Outcomes
- Practice patterns
- Adverse indicators
No pricing data is included. CRS is ideal for quality-first navigation and network refinement.
Smart Score
Smart Score incorporates the user’s own network-level pricing data into CRS to create a personalized value measure. This allows:
- Employers to identify high-quality and lower-cost providers
- Insurers to prioritize efficient providers for network design
- Medical tourism facilitators to align referrals with both outcomes and cost
Together CRS and Smart Score provide clarity that is tailored to each organization’s needs.
Why PRS Is Truly Bias-Free
Many provider directories and ranking tools rely on advertising, sponsorships, or opt-in participation. These models introduce conflicts of interest.
PRS does not allow any such influence because:
- Providers cannot pay to improve their ranking
- There is no manual curation
- There is no subjective scoring
- No self-reported data is accepted
- All evaluations are based on independently sourced claims data
This ensures complete neutrality.
Why Claims-Based Rankings Matter for Employers, Insurers, and Medical Tourism Professionals
Self-Insured Employers
High-value providers reduce unnecessary spending on surgeries, imaging, medications, complications, and reoperations.
Insurers and Network Developers
Procedure-level insights support better tiered networks, more effective contracting, and stronger centers of excellence programs.
Medical Tourism Facilitators
Objective rankings allow facilitators to identify providers who excel in very specific procedures. This improves patient outcomes and increases trust.
Digital Navigation and Concierge Platforms
API integration supports:
- Provider search tools
- Automated workflows
- Decision-support engines
PRS becomes the intelligence layer powering advanced navigation.
A Tool Designed for the Entire Healthcare Navigation Chain
PRS is built for scale and accessibility. It is delivered by subscription. It does not require installing software. It can be integrated through API. It supports comparisons at national, regional, and local levels. It applies to individual providers, group practices, hospitals, and ASCs.
It is versatile enough for benefit design, referral management, risk mitigation, cost containment, and patient guidance.
Why Claims-Based Provider Rankings Are the Future
Healthcare environments worldwide face increasing pressure to improve outcomes while controlling costs. Fragmented tools cannot meet these demands. Claims-based analytics that reflect real-world practice are now essential.
Denniston Data’s PRS provides:
- Holistic and procedure-level transparency
- Multi-payer and multi-year analysis
- Evidence-based and outcomes-informed insights
- Bias-free rankings
- Cost-quality alignment
For medical tourism professionals, employers, insurers, and digital platforms, PRS represents the new standard for precision in provider selection.
The future of healthcare navigation depends on objective evidence. Claims data provides that evidence more reliably than any other source.
The Medical Tourism Magazine recommends Denniston Data for anyone who islooking for high quality healthcare data analytics. Launched in 2020, DDI is aninnovator in healthcare data analytics, delivering price transparency andprovider quality solutions known as PRS (Provider Ranking System), HPG(Healthcare Pricing Guide), and Smart Scoring combining quality and price. Theyhelp payers, hospitals, networks, TPAs/MCOs, member apps, self-insuredemployers, and foreign governments identify the best doctors at the best pricesby procedure or specialty at the national, state, or local level, and by payeror NPI/TIN code.
Join an intro to PRS Webinar:
https://zoom.us/webinar/register/7117646163323/WN_2ELqNeDSS2W-fMPb4lOsRA
Or schedule a discovery call with Denniston Data:
