Private Insurance Reimbursement Rates

[OriginalBlend]

Is it normal for some private insurers to pay substantially less than Medicare? I'm new to CPT billing and my current position pays me based on a percentage of CPT code billed. I know what the 2021 Medicare rates are for common psych CPT codes, but the information provided from the company is showing some of the private large insurers as contracted for substantially less, most below $60 total for a 99213 across companies, or around $100 for a new 99204. Is this normal reimbursement or am I missing something? Thanks!

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[WisNeuro]

I use different codes, but that is true for a couple insurers in my region. I can easily fill a clinical panel without them, so most of my colleagues just don't bother to panel with the two that pay substantially less.

 

[OriginalBlend]

Thank you for your answer. This isn't really a small practice, it's actually a large mental health chain with like 20+ clinics in my state. $100 for a new patient 99204 and $55 for a 99213? I feel like the Medicaid clinics I worked at got reimbursed higher than that. I don't really get how they negotiated such bad rates?

 

[calvnandhobbs68]

Thank you for your answer. This isn't really a small practice, it's actually a large mental health chain with like 20+ clinics in my state. $100 for a new patient 99204 and $55 for a 99213? I feel like the Medicaid clinics I worked at got reimbursed higher than that. I don't really get how they negotiated such bad rates?

Those are pretty terrible rates. 100 bucks for a 99204 is straight up awful (like Medicaid awful).

That's the amount THEY'RE getting for a 99204 or the amount YOU'RE getting? If it's the amount you're getting that's not awful (I've seen it in for instance a 60/40 split so the actual reimbursed amount is more like ~150 for a 99204) but if that's the amount they're getting and then paying you a percentage of that, you're never gonna make any money.

 

[splik]

Thank you for your answer. This isn't really a small practice, it's actually a large mental health chain with like 20+ clinics in my state. $100 for a new patient 99204 and $55 for a 99213? I feel like the Medicaid clinics I worked at got reimbursed higher than that. I don't really get how they negotiated such bad rates?

Which insurance is this or is it several? Optum in particular is known for giving these terrible rates in some locales though I've even heard that BCBS can pay this badly. These do sound like bad rates. The other possibility is they are giving misleading information?

As an aside, 90792 and 99205 are probably more commonly used for initial visits. Sometimes 90792 pays more and sometimes 99204. For medicare 90792 pays more than 99204. Also 99214 is the most commonly used for follow ups. Particularly with the revisions if you have a pt with 2 stable problems and your prescribing a med, it's 99214, not 99213. I havent used 99213 in years AND I see several pts pts twice weekly.

 

[OriginalBlend]

They are saying that is what THEY get for those codes, and I get 60% of that. They showed the reimbursement sheet as a slideshow during my orientation, and I was able to jot down a few of them. They had Medicaid 99204 at something like $85, private insurer companies were like $100 to $130. Medicare was higher at like $150. For followups the 99213 code was like $55 for Medicaid, the private insurers were between $55 and $65, Medicare was highest at $70.

99214 was $75 to $85.

Again, the rates seem low and lower than anything I have seen. What are private insurers typically paying for the common E/M codes?

 

[calvnandhobbs68]

They are saying that is what THEY get for those codes, and I get 60% of that. They showed the reimbursement sheet as a slideshow during my orientation, and I was able to jot down a few of them. They had Medicaid 99204 at something like $85, private insurer companies were like $100 to $130. Medicare was higher at like $150. For followups the 99213 code was like $55 for Medicaid, the private insurers were between $55 and $65, Medicare was highest at $70.

99214 was $75 to $85.

Again, the rates seem low and lower than anything I have seen. What are private insurers typically paying for the common E/M codes?

It's going to vary from region to region, state to state and insurer to insurer.

I'll tell you from what I've seen recently looking at a few states and practices in the midwest at a mix of private insurers, 90792 was $150s-160s, 99204 was similar ($150s-160s), 99205 was ~$200 for most, 99213 was $70s-80s and 99214 was $100-120. But again this will vary widely (by like 50%+ in some cases) regionally and by insurer.

The Medicaid 99204 makes sense, Medicaid typically pays about 50%, maybe a little more, of what private insurance was typically paying in the states I looked. But the numbers they're giving for private insurance definitely seem low.

Just as an aside, don't mean anything by this but are you an NP/PA? I noticed your profile says non-student. If that's the case, it could be because they're actually billing 85% of physician rates as a possible explanation?

 

[vistaril]

Is it normal for some private insurers to pay substantially less than Medicare? I'm new to CPT billing and my current position pays me based on a percentage of CPT code billed. I know what the 2021 Medicare rates are for common psych CPT codes, but the information provided from the company is showing some of the private large insurers as contracted for substantially less, most below $60 total for a 99213 across companies, or around $100 for a new 99204. Is this normal reimbursement or am I missing something? Thanks

it's becoming pretty common sadly.

To make any money at these rates you obviously just have to 'stack em up' and grind.....good luck.

 

[TexasPhysician]

insurance rates can differ by side of the street. Part of it is how well you negotiate. I generally see commercial insurance rates at or above commercial rates, but some companies are terrible. You need to pick and choose, don’t accept them all.

 

[Mad Jack]

Any idea what going private rates would be good if you were working for a practice in the Northeast that only takes private insurance? For one hour initial evals, 99214s, 99213s, and therapy add-ons? I'm evaluating offers and trying to figure out if I'm getting lowballed, the offer seems pretty weak. This place is pure productivity with no base if that helps, set pay per patient seen

 

[clozareal]

Insurance rates I received:
90792 - $150-250
99204 - $150-200
99205 - $200-275
99214 - $100-160
90833 - $40-90
90836 - $50-125

 

[Mad Jack]

Insurance rates I received:
90792 - $150-250
99204 - $150-200
99205 - $200-275
99214 - $100-160
90833 - $40-90
90836 - $50-125

Hmmm, seems like I am getting lowballed hard. We're talking around $118 cut for a new intake, $65 for a 99214, $40 for a 90833. Given that it's straigh comp as an employee of a practice, it seems like I'd have to be seeing a lot of patients to make any decent salary.

 

[clozareal]

Hmmm, seems like I am getting lowballed hard. We're talking around $118 cut for a new intake, $65 for a 99214, $40 for a 90833. Given that it's straigh comp as an employee of a practice, it seems like I'd have to be seeing a lot of patients to make any decent salary.

Could be. It depends on the locality where you are providing services. These insurance rates are below what cash rates offer in my area.

 

[Mad Jack]

Could be. It depends on the locality where you are providing services. These insurance rates are below what cash rates offer in my area.

It's in a well-to-do area in the Northeastern region of the country. Client base is very high functioning, all private insurance. Most expect therapy with meds, so the vast majority of visits would be a 99214+90833, netting just north of $100 per visit. Factoring in no shows, it seems like it would be hard to make a decent income at these rates unless I'm churning out a lot of patients.

 

[calvnandhobbs68]

It's in a well-to-do area in the Northeastern region of the country. Client base is very high functioning, all private insurance. Most expect therapy with meds, so the vast majority of visits would be a 99214+90833, netting just north of $100 per visit. Factoring in no shows, it seems like it would be hard to make a decent income at these rates unless I'm churning out a lot of patients.

After or before the split? Like are they saying they only get reimbursed $65 for a 99214 or that's your portion of it? For example, a 60/40 split with one of the big places I was looking at last year would work out to about the same rate after the split. Yeah I thought it was a scam too, so I didn't take it...

 

[Mad Jack]

After or before the split? Like are they saying they only get reimbursed $65 for a 99214 or that's your portion of it? For example, a 60/40 split with one of the big places I was looking at last year would work out to about the same rate after the split. Yeah I thought it was a scam too, so I didn't take it...

This is after the split

 

[Sushirolls]

I'm in an atypical area of country, where I had two commercial paying less than medicare. Dropped one. Got the other to essentially match medicare.

The other private insurances pay better than what most of the country does, from what I can tell.

The really odd part is the larger Big Box shops in my area for medical services I personally had, were getting ~$290 ~$303 for 99214 with two different private insurance companies!

However, my area is also saturated with psych ARNPs.

 

[Mad Jack]

I'm very quickly understanding why people do cash-only PP

 

[Merovinge]

The really odd part is the larger Big Box shops in my area for medical services I personally had, were getting ~$290 ~$303 for 99214 with two different private insurance companies!

Geez, I can only imagine making $900/hour for 3x 99214s while accepting insurance. Some of the surgeons I know see 6x99214's in an hour...

 

[TexasPhysician]

Could be. It depends on the locality where you are providing services. These insurance rates are below what cash rates offer in my area.

Correct. I’ve seen half and double those rates based on location.

 

[Plimpington2]

I'm in northern Ohio and just started my own private practice after having been with a hospital system for the last 10 years. I am flabbergasted by how low my private insurance reimbursements have been so far. I have a very small sample size - so maybe things will get better - but I'm pretty discouraged right now.

Two examples:

Medicare lists rates as follows:

99205 - $245
99214 - $142

Today I got my very first reimbursement checks from a well known private national carrier.

99205 paid me $175
99214 paid me $83

Those are like MEDICAID rates! Those are awful, AWFUL, reimbursement rates for a private insurance carrier. I am at a total loss.

 

[splik]

I'm in northern Ohio and just started my own private practice after having been with a hospital system for the last 10 years. I am flabbergasted by how low my private insurance reimbursements have been so far. I have a very small sample size - so maybe things will get better - but I'm pretty discouraged right now.

Two examples:

Medicare lists rates as follows:

99205 - $245
99214 - $142

Today I got my very first reimbursement checks from a well known private national carrier.

99205 paid me $175
99214 paid me $83

Those are like MEDICAID rates! Those are awful, AWFUL, reimbursement rates for a private insurance carrier. I am at a total loss.

Did you not negotiate you fee schedules before you signed the contract?
99205 Ohio Medicaid pays $236.92 and 99214 is 122.27 apparently, so this is worse than medicaid!

 

[Candidate2017]

It's in a well-to-do area in the Northeastern region of the country. Client base is very high functioning, all private insurance. Most expect therapy with meds, so the vast majority of visits would be a 99214+90833, netting just north of $100 per visit. Factoring in no shows, it seems like it would be hard to make a decent income at these rates unless I'm churning out a lot of patients.

Northeast, well to do, high functioning patients who expect meds + therapy.

Short of telling us 95% of the patient population does yoga, I don't think there is anything else that could scream, "cash private practice" any louder.

 

[trophyhusband]

I'm in northern Ohio and just started my own private practice after having been with a hospital system for the last 10 years. I am flabbergasted by how low my private insurance reimbursements have been so far. I have a very small sample size - so maybe things will get better - but I'm pretty discouraged right now.

Two examples:

Medicare lists rates as follows:

99205 - $245
99214 - $142

Today I got my very first reimbursement checks from a well known private national carrier.

99205 paid me $175
99214 paid me $83

Those are like MEDICAID rates! Those are awful, AWFUL, reimbursement rates for a private insurance carrier. I am at a total loss.

Do those include the patient cost sharing (copay/coinsurance)? If not you need to include those to get a true comparison as Medicare would only pay you 80% of the rate you noted and then 20% would come from the patient or their supplemental insurance. It's probably still not great though.

 

[Plimpington2]

Do those include the patient cost sharing (copay/coinsurance)? If not you need to include those to get a true comparison as Medicare would only pay you 80% of the rate you noted and then 20% would come from the patient or their supplemental insurance. It's probably still not great though.

Those rates were the "allowable" rates. So, they included the cost sharing.

But what you said raises another question - if medicare only pays me 80% of what the published rate was, does that mean every patient has a 20% co-pay/co-insurance? What if the patient's card says they have no co-pay? I'm confused. How do I get that extra 20% from the patient if they insist they have no copay (or does every medicare patient have some kind of copay?)

 

[Sushirolls]

You look at the EOB.
The EOB will show you the break down of what a patient responsibility is, and what co-pay, coinsurance, deductible, etc they have.

 

[splik]

Those rates were the "allowable" rates. So, they included the cost sharing.

But what you said raises another question - if medicare only pays me 80% of what the published rate was, does that mean every patient has a 20% co-pay/co-insurance? What if the patient's card says they have no co-pay? I'm confused. How do I get that extra 20% from the patient if they insist they have no copay (or does every medicare patient have some kind of copay?)

Every original medicare pt has 80% paid by medicare. The other 20% they have to pay cash or their supplemental will cover it (i.e. medi-gap). If they have medicaid as 2ndary you may just eat the cost and only get that 80%. If they have medicare advantage plan, then that is different, they may pay more with the pt having a smaller copay.