Highest reimbursement?

[liquidshadow22]

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What are the highest reimbursement payments people have seen for 90792, 99214, 90833 via commercial insurance? $350?, $150, $75 respectively?

 

[splik]

I'm not sure this is a very helpful question unless you add qualifiers since there are differences between locality, insurances, and the size of your practice (and thus ability to negotiate). You can get widely different rates offered even in the same area. In my area, Medicare pays $226.90 for 90792, $153.23 for 99214, and $79.89 for 90833. So this gives you an idea that a good insurance should pay more than Medicare (though many pay less for solo practitioners). Big box shops often get 3x medicare rates from PPO plans so multiply the above by 3. In my area $300 is considered 50%ile for 90792 and $432 is the 90%ile. for 99214 $300 is considered 50%ile, and $577 is considered 90%ile, and for 90833 $127 is 50%ile, and $300 is 90%ile. This is based on sticker price, not necessarily what insurance reimbursed, but I can tell you the better plans do pay somewhat close to those sticker prices to the big systems. This is also in one of the most expensive areas in the country.

 

[liquidshadow22]

What are the highest reimbursement payments people have seen for 90792, 99214, 90833 via commercial insurance? $350?, $150, $75 respectively?

You're s

I'm not sure this is a very helpful question unless you add qualifiers since there are differences between locality, insurances, and the size of your practice (and thus ability to negotiate). You can get widely different rates offered even in the same area. In my area, Medicare pays $226.90 for 90792, $153.23 for 99214, and $79.89 for 90833. So this gives you an idea that a good insurance should pay more than Medicare (though many pay less for solo practitioners). Big box shops often get 3x medicare rates from PPO plans so multiply the above by 3. In my area $300 is considered 50%ile for 90792 and $432 is the 90%ile. for 99214 $300 is considered 50%ile, and $577 is considered 90%ile, and for 90833 $127 is 50%ile, and $300 is 90%ile. This is based on sticker price, not necessarily what insurance reimbursed, but I can tell you the better plans do pay somewhat close to those sticker prices to the big systems. This is also in one of the most expensive areas in the country.

You're saying big box shops can get $600 for 90792, $450 to $600 for 99214 in the most expensive locales of the country? This would be the sticker price or what is reimbursed? I assume this is California or Washington correct?

It's unbelievable how big of a gap there is from solo pp rates and groups, I don't get how it is financially advantageous for insurances to do this. The followup rate would be >$1000 per hour!!

 

[splik]

yup, see:

Many Hospitals Charge More Than Twice What Medicare Pays for the Same Care (Published 2020)

The gap between rates set for private insurers and employers vs. those by the federal government stirs the debate over a government-run health plan.

www.nytimes.com

Hospitals and Insurers Didn’t Want You to See These Prices. Here’s Why. (Published 2021)

Getting simple medical care at some hospitals can cost more with insurance than without.

www.nytimes.com

There are a couple of reasons for this. One is based on encouraging patients to receive all of their care in one place. Integration of care theoretically lowers overall costs. The second is that these places are negotiating rates across the board, and insurance companies may pay a higher rate for things like office visits, in order to get a better rate for things like procedures. Additionally, some of the big systems provide care for a sizeable proportion of the area and may be the only place to provide certain things (non-psychiatric), so the insurance companies can't afford to lose those systems from their network. Finally, there 80/20 rule means insurance companies don't have incentive to keep costs down since the ACA requires them to spend 80% of all premiums collected. Rather than bring costs down but reducing premiums, it has increased costs across the board (both cost of insurance premiums and how much they pay out).

But yes, from companies like Aetna and Anthem we get >$1000/hr. There are also people in pp who charge that rate.