Practice Management

A study published by The Urban Institute claims that various specialties are paid amounts significantly higher than Medicare. It's an interesting read:

Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty

Urban Institute		remove preview
Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty Private insurers generally pay physicians substantially higher rates than Medicare does for the same service. Policy proposals to reduce commercial prices and curb health care spending by benchmarking private payment rates to Medicare prices could therefore significantly affect physician payments, but the effects will likely vary considerably by specialty. View this on Urban Institute >

Anyone else find these numbers surprising?

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Rick Sylvanus
Operations Manager
Southern Delaware Imaging Associates
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Hi Rick

I'm very skeptical of the analysis.  I don't know of anyplace where physician reimbursement at 180% of Medicare is the norm for physicians...it certainly isn't nationwide.  Some places, commercial reimbursement is below Medicare.

I just skimmed through it, but my best guess is that somehow they have included a significant number of hospital claims in the mix.  If you factored in hospital claims and compared to the Medicare physician fee schedule, then 180% might be plausible, especially if you're looking at aggregate spending where TC would be more heavily weighted than PC.  I do believe the Fair Health database includes hospital claims, and I can't remember whether it's possible to split them out.

I'm sure some of our billing company friends could provide a more accurate analysis.

Dave

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David Smith FACMPE
Executive Director
United Imaging Consultants
Mission KS
(785) 393-8387
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Original Message:
Sent: 10-21-2021 13:53
From: Rick Sylvanus
Subject: Radiology paid 180% of Medicare from commercial carriers?

A study published by The Urban Institute claims that various specialties are paid amounts significantly higher than Medicare. It's an interesting read:

Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty

Urban Institute		remove preview
Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty Private insurers generally pay physicians substantially higher rates than Medicare does for the same service. Policy proposals to reduce commercial prices and curb health care spending by benchmarking private payment rates to Medicare prices could therefore significantly affect physician payments, but the effects will likely vary considerably by specialty. View this on Urban Institute >

Anyone else find these numbers surprising?

------------------------------
Rick Sylvanus
Operations Manager
Southern Delaware Imaging Associates
------------------------------

I'm not sure if the Fair Health data cited in this article is the same used for TX Arbitration but I have had the opportunity to review the TX Fair Health data quite extensively.

Those metrics range from, using weighted average volumes, a 50th percentile of around 165% to a 80th percentile of over 400%.
From the data I have you can't tell where the data was sourced from, all you get are the following columnar headings:


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Douglas G. Kraus, CPA
Chief Financial Officer
South Texas Radiology Group, P.A.
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Original Message:
Sent: 10-21-2021 14:13
From: David Smith
Subject: Radiology paid 180% of Medicare from commercial carriers?

Hi Rick

I'm very skeptical of the analysis.  I don't know of anyplace where physician reimbursement at 180% of Medicare is the norm for physicians...it certainly isn't nationwide.  Some places, commercial reimbursement is below Medicare.

I just skimmed through it, but my best guess is that somehow they have included a significant number of hospital claims in the mix.  If you factored in hospital claims and compared to the Medicare physician fee schedule, then 180% might be plausible, especially if you're looking at aggregate spending where TC would be more heavily weighted than PC.  I do believe the Fair Health database includes hospital claims, and I can't remember whether it's possible to split them out.

I'm sure some of our billing company friends could provide a more accurate analysis.

Dave

------------------------------
David Smith FACMPE
Executive Director
United Imaging Consultants
Mission KS
(785) 393-8387

Original Message:
Sent: 10-21-2021 13:53
From: Rick Sylvanus
Subject: Radiology paid 180% of Medicare from commercial carriers?

A study published by The Urban Institute claims that various specialties are paid amounts significantly higher than Medicare. It's an interesting read:

Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty

Urban Institute		remove preview
Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty Private insurers generally pay physicians substantially higher rates than Medicare does for the same service. Policy proposals to reduce commercial prices and curb health care spending by benchmarking private payment rates to Medicare prices could therefore significantly affect physician payments, but the effects will likely vary considerably by specialty. View this on Urban Institute >

Anyone else find these numbers surprising?

------------------------------
Rick Sylvanus
Operations Manager
Southern Delaware Imaging Associates
------------------------------

I can tell you that in Delaware, we are not anywhere near 180% from our commercial carriers.

Of course, we are impacted by the fact that there is essentially one commercial payer (Highmark) in the state that has probably 95% of the (non Medicare) business. Highmark has used their leverage to great effect.


------------------------------
Rick Sylvanus
Operations Manager
Southern Delaware Imaging Associates
------------------------------

Original Message:
Sent: 10-21-2021 13:53
From: Rick Sylvanus
Subject: Radiology paid 180% of Medicare from commercial carriers?

A study published by The Urban Institute claims that various specialties are paid amounts significantly higher than Medicare. It's an interesting read:

Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty

Urban Institute		remove preview
Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty Private insurers generally pay physicians substantially higher rates than Medicare does for the same service. Policy proposals to reduce commercial prices and curb health care spending by benchmarking private payment rates to Medicare prices could therefore significantly affect physician payments, but the effects will likely vary considerably by specialty. View this on Urban Institute >

Anyone else find these numbers surprising?

------------------------------
Rick Sylvanus
Operations Manager
Southern Delaware Imaging Associates
------------------------------

I have seen some states / practices in the 180% range but this is definitely not representative of national professional radiology reimbursement.  If I recall correctly the article has a disclaimer that the study "may not be representative of national rates".  It got that right at least...  :)

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Neale Pashley
Vice President, Partner Services
Collaborative Imaging
Plano TX
------------------------------

Original Message:
Sent: 10-21-2021 13:53
From: Rick Sylvanus
Subject: Radiology paid 180% of Medicare from commercial carriers?

A study published by The Urban Institute claims that various specialties are paid amounts significantly higher than Medicare. It's an interesting read:

Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty

Urban Institute		remove preview
Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty Private insurers generally pay physicians substantially higher rates than Medicare does for the same service. Policy proposals to reduce commercial prices and curb health care spending by benchmarking private payment rates to Medicare prices could therefore significantly affect physician payments, but the effects will likely vary considerably by specialty. View this on Urban Institute >

Anyone else find these numbers surprising?

------------------------------
Rick Sylvanus
Operations Manager
Southern Delaware Imaging Associates
------------------------------

I actually located a Rand Study that provides state level (actually, even hospital level) data. It's a dense read but shows that in the state of Delaware, 110% is average which seems much more realistic. (The "Support Files" that can be downloaded provide lots of detail.)

The Rand study:
https://www.rand.org/pubs/research_reports/RR4394.html

------------------------------
Rick Sylvanus
Operations Manager
Southern Delaware Imaging Associates
------------------------------

Original Message:
Sent: 10-27-2021 16:24
From: Neale Pashley
Subject: Radiology paid 180% of Medicare from commercial carriers?

I have seen some states / practices in the 180% range but this is definitely not representative of national professional radiology reimbursement.  If I recall correctly the article has a disclaimer that the study "may not be representative of national rates".  It got that right at least...  :)

------------------------------
Neale Pashley
Vice President, Partner Services
Collaborative Imaging
Plano TX

Original Message:
Sent: 10-21-2021 13:53
From: Rick Sylvanus
Subject: Radiology paid 180% of Medicare from commercial carriers?

A study published by The Urban Institute claims that various specialties are paid amounts significantly higher than Medicare. It's an interesting read:

Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty

Urban Institute		remove preview
Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty Private insurers generally pay physicians substantially higher rates than Medicare does for the same service. Policy proposals to reduce commercial prices and curb health care spending by benchmarking private payment rates to Medicare prices could therefore significantly affect physician payments, but the effects will likely vary considerably by specialty. View this on Urban Institute >

Anyone else find these numbers surprising?

------------------------------
Rick Sylvanus
Operations Manager
Southern Delaware Imaging Associates
------------------------------