how do medicare or insurances decide on how much a physician service is reimbursed?

[donaldtang]

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I am curious on how do medicare or insurance companies make decisions on how much they reimburse a specific type of physician service? How do they evaluate if one type of service or service from one specialty is more "valuable" than the other?

 

[typhoonegator]

There's also an inflation adjustment scale that is applied based on the Congressional budgetary allocation, as well as closer examination of utilization rates of particular procedures/codes that represent big money sinks for Medicare.

 

[typhoonegator]

Yeah, I get that. It's just that the inflationary/cost of business adjustments tend to get a lot of news coverage, or the sudden cuts in particular procedures (EMG for example) that get everyone in a tizzy.

 

[notinkansas]

Basically a committee of bureaucrats decides.

 

[gutonc]

Basically a committee of bureaucrats decides.

This is true - ish. But the bureaucrats are physicians. And mostly surgeons. Which is one (of many) reasons that procedural specialties are better reimbursed than non-procedural ones.

 

[donaldtang]

Then how are the people on the committee selected/elected? Who are eligible to be candidate?

 

[gutonc]

Then how are the people on the committee selected/elected? Who are eligible to be candidate?

Start with being part of the AMA (if you can stomach that). Then go to basically every meeting/conference they have and kiss ass until your lips are dark brown. At that point, you'll be on the short list.

 

[notinkansas]

This is true - ish. But the bureaucrats are physicians. And mostly surgeons. Which is one (of many) reasons that procedural specialties are better reimbursed than non-procedural ones.

When I learned from a breast surgeon that a mediport has more RVU than a mastectomy (because Interventional Radiology also does mediports and therefore that procedure has more clout on the committee for more RVU), that's when I realized how truly F'd up this system is.

 

[gutonc]

When I learned from a breast surgeon that a mediport has more RVU than a mastectomy (because Interventional Radiology also does mediports and therefore that procedure has more clout on the committee for more RVU), that's when I realized how truly F'd up this system is.

Not sure what attending was lying to you about this, but in the 2014 RVU data, a port placement is worth 10 RVUs while a MRM is (almost) 34 and the LN biopsy is 20-25 RVUs, depending on how you code it. Sure, you could do 4 or 5 port-a-caths in the time it took to do one mastectomy so if you just spend your day placing ports, you can probably make a lot more money.

I'm not saying the way RVUs are determined is rational, reasonable or logical. But don't just straight up lie about the numbers.

 

[Winged Scapula]

Since I think I'm the attending that @notinkansas is speaking of, I believe I was misquoted. In addition, it was before 2014 when many procedures were bundled to include the imaging component.

I didn't state that the RVUs for ports was more than mastectomy (especially since I have absolutely no idea what RVUs for the procedures I do are) but that the allowable reimbursement was more than for a mastectomy due to all the individual components. Given the imaging component (at that time) plus the fact that you could do 4 ports in the time it takes to do a mastectomy (and turn over the room), it used to be more profitable (because you billed for doing the imaging, for image guidance during vascular access, for placement of the port, for fluro time when threading the catheter, and final image review). But yes, if you could schedule 4 or 5 ports in 1 hour (having rooms to jump back and forth between), you could make more than a mastectomy.

I have also stated that, in the past, I made more for an image guide core needle biopsy of the breast than a mastectomy. Reimbursement for the former has dropped substantially now that everything is bundled together into one code. RVUs for sentinel node biopsies used to be undervalued and have recently increased.

That being said, reimbursement scales are screwed up and even amongst surgeons, skewed toward certain specialties.

 

[gutonc]

That being said, reimbursement scales are screwed up and even amongst surgeons, skewed toward certain specialties.

And this is really the key to it all.

 

[deleted480308]

Since I think I'm the attending that @notinkansas is speaking of, I believe I was misquoted. In addition, it was before 2014 when many procedures were bundled to include the imaging component.

I didn't state that the RVUs for ports was more than mastectomy (especially since I have absolutely no idea what RVUs for the procedures I do are) but that the allowable reimbursement was more than for a mastectomy due to all the individual components. Given the imaging component (at that time) plus the fact that you could do 4 ports in the time it takes to do a mastectomy (and turn over the room), it used to be more profitable (because you billed for doing the imaging, for image guidance during vascular access, for placement of the port, for fluro time when threading the catheter, and final image review). But yes, if you could schedule 4 or 5 ports in 1 hour (having rooms to jump back and forth between), you could make more than a mastectomy.

I have also stated that, in the past, I made more for an image guide core needle biopsy of the breast than a mastectomy. Reimbursement for the former has dropped substantially now that everything is bundled together into one code. RVUs for sentinel node biopsies used to be undervalued and have recently increased.

That being said, reimbursement scales are screwed up and even amongst surgeons, skewed toward certain specialties.

It's one of the problems with the market not determining pay....a random government committee is neither the patient needing the procedure nor the provider with the costs to cover.