List of Medicare rates?
December 14, 2008 11:01 AM   Subscribe

Where do I get a list of Medicare payment rates for surgical procedures?

I am currently involved in an insurance appeal over a robotic excision of a tumor in my pelvis. My insurance company only wants to pay a small fraction of the cost of the surgery, saying that since I was out of network, they only have to pay Medicare rates for the surgery. It would be helpful in my appeal if I could find a list of Medicare rates for various surgeries, and see if Medicare even has rates for robotic excision. Can anyone point me in the direction of a list of rates? Google hasn't provided any results that tell me what I need to know.
posted by twiggy32 to Health & Fitness (4 answers total) 3 users marked this as a favorite
Here's a link that offers some fee schedules in pdf form. I don't see surgical procedures listed, but maybe you can dig further.

When I worked in a medical office, we got a giant printout each year, directly from Medicare, telling us exactly how much they would pay for each procedure and service we performed. If your insurance company has such a list that they're basing their decision on, maybe you could ask them for a copy of it?
posted by amyms at 11:26 AM on December 14, 2008

Medicare surgical fee schedules vary geographically. Your profile doesn't give your location, but if you post it or mefi-mail me, I believe I can find the information for you.

Medicare will have separate fee schedule amounts for the physician service, the hospital/facility, anesthesia, etc. It would be very helpful to know what procedure code(s) the physician billed for the procedure.
posted by Snerd at 12:18 PM on December 14, 2008

Response by poster: Thanks, Snerd. Check your mefi-mail.
posted by twiggy32 at 12:45 PM on December 14, 2008

Best answer: Twiggy32, I'm sending Mefi-mail with some payment information specific to your locality & procedure. Amyms was on the right track. CMS (Centers for Medicare and Medicaid Services) offers a physician fee schedule search by locality. If you know the 5-digit procedure code, you can look up the payment amount for the physician.

Ambulatory Surgery Center (ASC) payments are made separately, and CMS also has these fees online.

If the procedure is done in a hospital, "Addendum B" has a much longer list of payment amounts. National payment rates are listed; adjustments are made based on local labor costs of the metro area or state, so that (for example) New York City payments are higher than in a rural area in the midwest. But the national payment rates give you an idea what the hospital is paid by Medicare, and should let you confirm what your insurance plan is telling you.

The other part of your question was whether Medicare pays higher rates for robotic surgery. It looks like they do not. Intuitive Surgical, makers of the da Vinci robotic surgery system, has a frankly labeled "Reimbursement SellSheet" (pdf) online. I also found a presentation by an Intuitive rep on the subject. While they promote financial advantages of robotic surgery, higher payment doesn't seem to be one of them.

Although your health plan says they'll only pay Medicare rates for your out-of-network surgery, the same Medicare rates can be a starting point for your negotiation with the provider. The provider shouldn't expect a higher payment than your plan would have paid for in-network care. A mutually agreeable amount could be somewhere in between.
posted by Snerd at 4:12 PM on December 14, 2008

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