Utilizing the Medicare Physician Fee Schedule Tool

Utilizing the Medicare Physician Fee Schedule Search Tool

It’s important for you to know how much you’ll be paid for the services you’re providing.  Many people get confused by their billing system because it will show a charge amount that’s much higher than the actual allowed amount.  Coupled with the fact that most commercial insurance companies utilize Medicare for their fee schedules, it’s next to impossible to track allowed amounts without understanding the various Medicare fee schedules utilized by the payers.

The allowed amount (which is what you’ll be paid before coinsurance or deductibles are taken out) is what you’re actually eligible to receive from the different payers.  Medicare sets the standard for most commercial payers and they all pay a percentage of the Medicare fee schedule. We put together a video a few years ago that helps understand how to use the tool provided by Medicare to research your top CPT codes.  Remember to research the fee based on your region or locality.  Also, remember to pay special attention to what year Medicare fee schedule the payer is utilizing.


the importance of understanding your medicare fee schedule

Aside from the obvious benefits of just understanding how you’re being paid, building your reimbursement schedule provides you the knowledge you need to effectively renegotiate your insurance contracts in the coming years.  Simply knowing that UHC is paying based on a percentage of 2012 Medicare and BCBS is paying based on 2016 Medicare, provides little to no value if you don’t know how those two fee schedules compare.  Oftentimes, you’ll find that 2012 will pay more for certain codes, let’s say procedure codes, where 2016 will pay more for E&M codes. 

Evaluating the difference between those two years is the first step, the next and most critical step is seeing how those differences will affect your revenue.  This is where conducting a weighted evaluation of your top codes is critical.  This will show you in actual annualized revenue the material impact of changes to your fee schedule.  For more information on conducting an evaluation of your fee schedules, we recommend watching our video on insurance contract evaluation referenced here and below.

In addition, don’t hesitate to reach out if you need assistance evaluating your insurance contracts and if warranted, negotiating those contracts with to obtain a better fee schedule and/or more favorable terms.

Insurance Contract Negotiation Service

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