Practice Management

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  • 1.  Private Payer Rates

    Posted 06-01-2021 10:20

    I am new to RBMA.  I am trying to find surveys/statistics on insurance payer rates and don't see them on this website.  I am a part of a multi-specialty group in Central Florida.  The anesthesiologists in our group are able to see detailed insurance payer rate information for groups through their equivalent anesthesia business association.  

    I am wondering if anybody knows if this data is already available on the RBMA website.  If not, I wonder if anybody would be interested in the creation of such a document.  We could anonymize data and create a spreadsheet showing ranges and averages for insurance payer rates (e.g. BCBS @ 150% of medicare, etc).  Also perhaps break them down by location and rural/urban settings.

    Is this data available already?  If not, should we work on putting it together for groups to use as a reference/place to start when negotiating payer rates​ with insurance companies?


    Thanks,

    Greg



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    Gregory Benke MD
    Diagnostic Radiologist/Co-Chair of BPA Radiology
    Brevard Physician Associates
    Melbourne FL
    (321) 837-3820
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  • 2.  RE: Private Payer Rates

    Posted 06-01-2021 13:34

    I don't think we are allowed to do such; per Federal rules and regulations.

     

    DENNIS WISEMAN

    Chief Executive Officer

    Radiology & Imaging of South Texas

    3226 S. Alameda Street

    Corpus Christi, TX 78404

    (O) 361-888-6684 ext. 2046

    (F) 361-853-4454

    (C) 786-223-2671

     

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  • 3.  RE: Private Payer Rates

    Posted 06-02-2021 08:12
    I've been around awhile and have always operated under the rules of an individual group's contracted rates should always be kept confidential.  But I think we also have to understand the current environment.  Seems everyone is pushing for more transparency on contracted rates.  Hospitals are suppose to disclose their rates openly on their website for all payers.  I hear comments sometime about radiology groups preparing for their hospitals to start requesting the radiology group do the same.  Makes me wonder if we're to the point where the confidential nature of our respective contracted rates may be changing.

    Just my thoughts on this topic......Chris

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    R. Christopher Sluder CPA
    Administrator
    Rome Radiology Group
    Rome GA
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    Original Message


  • 4.  RE: Private Payer Rates

    Posted 06-02-2021 09:12
    Setting aside the fact that contracts commonly contain confidentiality language, the real obstacle to RBMA acting as a clearinghouse for rate information, and to groups using it, is the risk of running afoul of anti-trust law.  I'm not a lawyer, but as I understand it, if RBMA gathered and published data about contract rates, and groups started negotiating based on that data, there could be charges of illegal collusion. 

    There is certainly history of other similar organizations facing charges of price fixing as a result of these kinds of activities, and most try to steer well clear of them.  It's pretty surprising that the anesthesia group would venture into that minefield.

    If you operate within the law (i.e. negotiate independently), then I don't think knowing what others get paid would materially change your negotiating position.  If I know what the other groups in my market are getting, I don't think it would change much, because they are situated differently in terms of their service mix, scale, market coverage, hospital affiliations, etc.  My goal is to optimize our reimbursement for my groups situation, and what others are getting isn't really relevant to me...nor can it be.  Of course, if a payor is offering something below what we get from their peers, I won't hesitate to use that information.

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


  • 5.  RE: Private Payer Rates

    Posted 06-02-2021 12:24

    One can use CMS's Medicare Provider Utilization and Payment Data file to determine nearly any group's fees at the procedure level, and do so with a high level of accuracy.  This data file contains both charges and payments by CPT code, by doctor, by address, city, state, zip, etc.  Using this publicly available data I've been able to recreate several groups fee schedules.  There are a few things one needs to understand about the data structure in order to do this, some of which may not be intuitively obvious at first glance.  You must also have a reasonable understanding of Access and query design.  

    The chart below is a general indication of one way I used the data.  Using publicly available data, I was able to determine the overall Multiple of Medicare to which their charges were set, i.e. the ratio of their charges to Medicare Allowable.  The underlying data I used to create this chart was by CPT code which means I also had their specific charges for each procedure code which I could also use to recreate an entire fee schedule.  For purposes of this chart, I simply aggregated them for discussion purposes.  It gave me a very good sense of how our fees compared to my selected benchmark groups. Interestingly, the last column on the right is for a group that must set the charges for their Medicare business at the Medicare Allowable rate – an anachronism in recent years. 

    Here are links to two LinkedIn articles I wrote a few years ago comparing how overall Charges (expressed as a Multiple of Medicare Allowable) varied between states.  Again, it is important to note that the underlying data was very granular (e.g., at the provider/address/CPT code level) which means I could just have easily posted a specific group's fee schedule had I wanted to do so.

     

    Mike Bohl

     

    Variation of Professional Component Radiology Charges by State Based on the 2014 Medicare Physician Payment File Data | LinkedIn

     

    Variation of Professional Component Radiology Charges by State Based on the 2014 Medicare Physician Payment File Data, Part 2 | LinkedIn

     

     

     

     




    Original Message


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