Jane Dotson
Finding out insurance reimbursement rates can be a difficult and inconsistent process. In the US, Medicare and Medicaid rates are set by the Federal or state government, respectively, and can be found on the CMS website. Private insurers may use Medicare rates to set out-of-network reimbursement rates, and FAIR Health offers benchmark charge data that insurers may use to inform their out-of-network reimbursement rates. Additionally, insurance companies will provide a fee schedule, typically in the form of a spreadsheet or PDF document, which outlines reimbursement rates. CPT codes, which are standardized across insurance companies, can be used to search for specific reimbursement rates within these documents.
| Characteristics | Values |
|---|---|
| How to find insurance reimbursement rates | Fee schedules are sent by insurance companies in the form of a spreadsheet or PDF document, either before or after signing a contract. |
| CPT codes can be used to search for specific reimbursement rates within these documents. | |
| Medicare rates can be used to estimate reimbursement rates, as some private insurers use Medicare rates to set out-of-network reimbursement. | |
| FAIR Health offers benchmark charge data that some insurers may use to inform their rates for out-of-network reimbursement. | |
| Reimbursement rates can vary based on factors such as license, state or city, insurance plan, number of providers in-network, and specialty. |
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What You'll Learn
Understanding fee schedules
Fee schedules are typically developed by healthcare providers in collaboration with insurance companies, government agencies, and other relevant stakeholders. These schedules are often based on various factors, including the complexity of the procedure, the time and effort required, the cost of supplies and equipment, and the prevailing market rates for similar services in the region. For example, Medicare, the federal health insurance program in the United States, has its own fee schedule known as the Medicare Physician Fee Schedule (MPFS). The MPFS assigns relative value units (RVUs) to each procedure, which are then multiplied by a conversion factor to calculate the reimbursement amount.
It's important to note that fee schedules are confidential, and sharing them with colleagues could put your practice at risk. The fee schedule is typically provided by the insurance company as a spreadsheet or PDF document before or after signing a contract with them. This document is important to keep on hand to monitor and audit the amounts paid by the insurance company, as mistakes can occur. Additionally, CPT codes, which are standardized codes for individual therapy, intakes, and group therapy, can be used to search for specific rates within the fee schedule.
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CPT codes
To find reimbursement rates for CPT codes, you can refer to the Medicare Physician Fee Schedule (MPFS). The MPFS is a comprehensive list of reimbursement rates that can be searched using CPT codes. It is updated quarterly to reflect changes in reimbursement rates. By locating the CPT code on your bill from your healthcare provider, you can then search for that code in the MPFS to find the corresponding reimbursement rate.
Additionally, Medicare reimbursement rates can be used as a reference for insurance reimbursement. Medicare rates are typically lower than private insurance rates, usually covering around 80% of the total bill, with the remaining 20% being the beneficiary's responsibility. The Medicare rates can be found on the CMS website, which includes a vast spreadsheet with thousands of CPT codes and their associated rates. While this provides a general sense of reimbursement, it is worth noting that actual payment methodologies can vary based on factors such as geography, local wage rates, and hospital type.
Insurance companies typically provide fee schedules in the form of spreadsheets or PDFs. These documents can be requested before or after signing a contract with the insurance company. Within these schedules, you can search for specific CPT codes that you will be billing to identify the corresponding reimbursement rates. Common CPT codes to look for include 90791 and 90837. Using keyboard shortcuts, such as Ctrl + F, can be helpful for searching for specific codes within these large documents.
It is important to remember that reimbursement rates can vary across insurance companies and are subject to change annually. Therefore, staying updated with the contracted rates for each CPT code is essential for managing revenue expectations in your practice.
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Medicare rates
Medicare reimbursement rates refer to the monetary amounts that providers are paid by the Centers for Medicare and Medicaid Services (CMS) for services provided to Medicare beneficiaries. These rates are based on a reimbursement formula that considers various factors to ensure equitable compensation.
The original objective of Medicare was to establish a uniform payment system to minimise disparities between varying usual, customary, and reasonable costs. Today, Medicare reimbursement rates are applied across all medically approved procedures and services provided to Medicare enrollees. The rates paid will apply to all medical claims received from authorised healthcare professionals.
Medicare establishes these reimbursement rates based on recommendations from a select committee of specialists, composed of medical professionals and others nominated by professional societies. While Medicare is not obligated to accept all recommendations, it has routinely approved more than 90% of them.
Reimbursement rates are calculated using the resource-based relative value scale (RBRVS), which combines three main categories: the provider's work, practice expenses, and liability insurance. These variable amounts, known as relative value units (RVUs), are adjusted for location using the geographic practice cost index (GPCI).
The CMS provides CPT code reimbursement lookup tools to calculate reimbursement rates. On the CMS website, you can find a Medicare fee schedule lookup where you can enter the codes for services and determine potential payments. Additionally, the PFS lookup tool aids physicians and non-practitioners in finding PFS payment rates.
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State-set rates
State-set insurance reimbursement rates are determined by the state government. In the US, Medicare and Medicaid rates are set by the Federal government (Centers for Medicare and Medicaid Services) or state government, respectively. States have historically set their own Medicaid reimbursement rates, which have varied widely. The Medical Assistance (MA) rate is a state's standard reimbursement rate for Medicaid-covered services. Each state determines how it will reimburse Medicaid recipients. For example, some states reimburse for each service provided during an encounter (a face-to-face interaction between the patient and healthcare provider), while others set a flat fee for each encounter.
Medicaid reimbursement rates for certain primary care services were required to match Medicare rates due to a federal mandate in 2013. This reduced the dramatic geographic variation in reimbursement rates, with average Medicaid payments increasing by 60%. However, there was still substantial variation across states, with rates remaining unchanged in two states and more than doubling in 11 others.
Medicare reimbursement rates are monetary amounts paid to healthcare providers, hospitals, laboratories, and medical equipment companies for services and supplies provided to Medicare enrollees. These rates are established by Medicare based on recommendations from a select committee of specialists, including medical professionals and others nominated by professional societies. The rates are complex, multifunctional, and revised annually, taking into account various factors and geographical locations.
To access state-set reimbursement rates, you can refer to the CMS website, which publishes the Indian Health Service (IHS) rate, an all-inclusive rate reimbursed for Medicaid-covered services. Additionally, state-specific websites or databases may provide information on reimbursement rates set by the state government. It is important to note that commercial insurance company rates can vary based on factors such as your license, the state or city you work in, and the insurance plan.
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FAIR Health's benchmark charge data
FAIR Health is a national, independent, non-profit organization that aims to bring transparency to healthcare costs and health insurance information. It is regarded as a trusted and neutral provider of data and data tools by diverse stakeholders in the healthcare sector. FAIR Health possesses the nation's largest collection of private healthcare claims data, with over 51 billion claim records contributed by payors and administrators of private insurance plans.
FAIR Health offers benchmark charge data that some insurers may use to inform their rates for out-of-network reimbursement. The organization's in-house experts in statistics, economics, and technology rigorously validate the data to ensure its reliability. The FAIR Health database contains over 44 billion billed medical and dental procedures from 2002 to the present, with more than 2 billion new claim records added annually. The data is organized by procedure and geographic location, making it convenient for users to access relevant information.
The cost benchmarks provided by FAIR Health include charge and allowed amounts. The "allowed amount" is FAIR Health's estimate of what an insurer may pay an in-network provider for a particular service. These allowed amounts are organized into percentiles for each geozip, with a geozip being a geographic area based on the first three numbers of a zip code. This grouping ensures that the costs represent what providers actually charge in a specific area.
FAIR Health also offers a tool called FH Fee Estimator, which displays charge benchmarks based on actual data for each procedure code/geozip combination. The charge benchmarks are presented as a range of charges for each procedure in each geozip and are organized into percentiles. If there are not enough occurrences of a given procedure code/geozip combination in the database, a relative value methodology is used to derive a benchmark charge.
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Frequently asked questions
Insurance reimbursement rates can be difficult to find and are dependent on several factors, including your location, license, and insurance plan. The best way to find reimbursement rates is to consult the fee schedule, which is a spreadsheet or PDF document that insurance companies should provide before or after you sign a contract with them. CPT codes can help you navigate these documents.
CPT codes are standardized codes for individual therapy, intakes, and group therapy. CPT stands for Current Procedural Terminology.
Yes, you can look at Medicare rates, which are published by the CMS. Some private insurers use Medicare rates to set out-of-network reimbursement, so this can give you a general idea of what you might be paid. FAIR Health also offers benchmark charge data that some insurers may use to help inform their rates for out-of-network reimbursement.
