Medicare Bulk Check Detail Report - Different Payment for Same Procedure

I am new and was looking at the ETF deposit of a Medicare check for a practice. The contracted/allowable amount for this doctor for a 99213 is $66.38. The check posts automatically to the system.


Reviewing the deposit report, not all 99213's on this MC check have the allowable as this amount, some have 56.42. Shouldn't all the 99213's have the same amount for allowable, with the adj, deductibles and co-pays showing the differences?

Response:

I understand your frustration. Medicare payment information can be difficult to understand. One possible reason for the difference is due to the place of service. Medicare reimbursement can differ based on where the procedure was performed. Typically if the procedure is performed at a facility such as a hospital, the reimbursement is lower than if it was performed in the providers office - a non-facility location.

Medicare has something called a RVU - Relative Value Unit. This RVU is applied to the reimbursement and accounts for the adjustments to the payment. The location is just one of the factors in the adjustment. Medicare also makes periodic adjustments that effect reimbursements - you may check to see if something like that has taken effect recently.

You can checkout Medicare's Physician Fee Schedule page for more information. This also has info on some of the changes they make effecting the fee schedule.

Hope this helps. I don't know that I can offer a definitive answer on this - like you I am many times puzzled by Medicare's reimbursement practices.

If anyone has any other info or insight please do so by clicking the "Click here to post comments" link below.

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