Medicare reimbursement

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liquidshadow22

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Do rates vary by state? What is the typical reimbursement for a 25 minute med mgmt visit or 1 hour initial?
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would it be reasonable to decide where to start practicing based on reimbursement levels?
 
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I've been trying to understand how they use the conversion factor to calculate the reimbursement rate.

In my locality the GPCI is 1.000
The 2019 conversion factor is 36.0391
I went and looked up the reimbursement for a 99214. Says that the non-facility price is $107.03 and the facility price is $78.70
The RVUs per 99214 are 1.5.
I was under the impression that the way to calculate the reimbursement was to multiply the RVUs by the conversion factor, which would give a price of roughly $54.06. That's (thankfully) less than the listed non-facility and facility prices.
I tried this for some other CPT codes as well (inpatient codes, consultation codes, ECT). Seems like the calculated price when I do this multiplication of conversion factor by RVUs is always less than the listed facility and non-facility prices.

Is there some other part of the formula that I'm missing?
 
liquidshadow22 said:
would it be reasonable to decide where to start practicing based on reimbursement levels?
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There's little variation in areas that sustain insurance-driven practices for you to leverage this. In areas where geographical adjustment makes a meaningful difference, practices either take cash, or have separate carve-outs with either state government (Medicaid) or private insurance. Typically how this works is that for a CHMC you take fee for service Medicare reimbursement for the dually eligible SMI patients, then if there's a shortfall ask for the state to make you whole. You can think of Medicare as a federal subsidy to the state in caring for the SMI population.

I would say taking Medicare is somewhat uncommon in private practice, which makes it hard for specific population sectors to get care--i.e. people over 65 who aren't SMI but also don't have enough savings to do cash treatment. This is a decent chunk but given the various bigger fish to fry in our current mental health non-system, not a lot of attention is being paid to this. Lower middle-class retirees say with late-life depression and commit suicide or slowing withering outpatient dementia are not getting on anyone's agenda at the moment.
 
Psych19 said:
I've been trying to understand how they use the conversion factor to calculate the reimbursement rate.

In my locality the GPCI is 1.000
The 2019 conversion factor is 36.0391
I went and looked up the reimbursement for a 99214. Says that the non-facility price is $107.03 and the facility price is $78.70
The RVUs per 99214 are 1.5.
I was under the impression that the way to calculate the reimbursement was to multiply the RVUs by the conversion factor, which would give a price of roughly $54.06. That's (thankfully) less than the listed non-facility and facility prices.
I tried this for some other CPT codes as well (inpatient codes, consultation codes, ECT). Seems like the calculated price when I do this multiplication of conversion factor by RVUs is always less than the listed facility and non-facility prices.

Is there some other part of the formula that I'm missing?
Click to expand...
The RVU of 1.5 for 99214 is the wRVU, not the tRVU. The total RVU is where you will likely get "the same number."
 
For further education, clarification, my practice is a simple office. I hung a shingle, so to speak, and do take medicare. I get the non-facility fee rate. Which means I am not a large non-profit facility like a hospital or Acute Care Surgery center, etc. Those locations get a lower professional fee in the eyes of Medicare, which is the "facility fee" rate, because they ALSO get the opportunity to submit another bill just for facility fees.

By me being a simple office based practice, with the ability to capture the larger non-facility fee, the three components of an RVU are all mine - professional, facility, liability - and built into the fee that medicare pays me. The three components together equal tRVU.

Most of what you will see written on SDN refers to wRVU (work RVU) because they are employed jobs, and employers are taking the facility/liability component for themselves.
 
recently looked at a telepsych job at CMHC that sees mainly medicaid pts. They offer $100 per initial eval and $65 per followup. The initial eval rate seems really low to me. Is this a bad deal? supposedly the pt population is not very severe and they are doing 15 min med checks and 30 min initials, but theyre not strict about time requirements for seeing pts.
 
liquidshadow22 said:
recently looked at a telepsych job at CMHC that sees mainly medicaid pts. They offer $100 per initial eval and $65 per followup. The initial eval rate seems really low to me. Is this a bad deal? supposedly the pt population is not very severe and they are doing 15 min med checks and 30 min initials, but theyre not strict about time requirements for seeing pts.
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Bad deal unless they have phenomenal support staff which these clinics rarely do. CMHC patients are often complicated and require SW&case management collaboration. Also they often have chronic health problems that affect treatment which means you also often have to coordinate with a PCP. Even if the intakes are short bc the patient is psychotic, it’s hard to imagine doing the interview, paperwork, labs (lots of clozapine & lithium ) in 30 min. Same goes for FUs. Also lots of no shows so you would have to double book or take a hit. I predict $150-180/hour would be the actual rate.

I am in a similar setting but salaried and get 1 hour for intakes and 30 min for follow ups.
 
Sushirolls said:
For a CMHC that's probably good rate.
Hard to say what the actual work involved will be for that...
Click to expand...

Why is it a good rate?Pretty sure if it were Medicare pts you can easily bill near $200 for initial evals correct?
 
Ironspy said:
Bad deal unless they have phenomenal support staff which these clinics rarely do. CMHC patients are often complicated and require SW&case management collaboration. Also they often have chronic health problems that affect treatment which means you also often have to coordinate with a PCP. Even if the intakes are short bc the patient is psychotic, it’s hard to imagine doing the interview, paperwork, labs (lots of clozapine & lithium ) in 30 min. Same goes for FUs. Also lots of no shows so you would have to double book or take a hit. I predict $150-180/hour would be the actual rate.

I am in a similar setting but salaried and get 1 hour for intakes and 30 min for follow ups.
Click to expand...

150-180 would be optimistic..
 
liquidshadow22 said:
Why is it a good rate?Pretty sure if it were Medicare pts you can easily bill near $200 for initial evals correct?
Click to expand...
State medicaid rates are posted online as public knowledge in most states. You can see the Fee schedule. Some states offer some CMHC clinics a slightly higher rate then community private practice folks, but even with those designated increased rates, you'll see how low medicaid is. That's why my statement says for medicaid, it's good. Anything else, no. But as isonspy pointed out, the reality of the work is completely different then the pay rate...
 
30 mins for new eval - i wouldnt take it. Minimum 1 hour, most counties I have been give 1 hour 30 mins for new evals, and 30 mins for follow up. Also show or no-show, you get paid. Do not sign for anything less than $180/hour
 
does medicare typically reimburse only like 50% of whatever is charged in terms of the CPT codes by the physician as "allowable"?
 
I realize you can look up the provider amount on there but I hear that they typically don't reimburse that amount fully. Is that true?
 
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