Krause Trudy Millard, Ukhanova Maria, Revere Frances Lee
Tex Med. 2016 Jun 1;112(6):e1.
This research evaluated the 2013 published physician reimbursement rates for Medicare and Medicaid in Texas and compared the rates with the mean fees from private carriers. Physician claims data were extracted from the Truven MarketScan Commercial Claims Databases. The average allowed amounts per unit per procedure code were compiled. The 2013 Medicare physician fee schedule was obtained and filtered to Texas. The 2013 Texas Medicaid physician fee schedule was obtained. The mean commercial allowed amounts were compared with those of Medicare and Medicaid on a per-unit rate. Comparison ratios were derived for each code. The CPT© procedure codes were then grouped into the categories assigned by the American Medical Association. The ratios of private/Medicare and private/Medicaid varied greatly by procedure type and locality, with the Texas Medicaid fees well below both private and Medicare fees. The discrepancy in payment amounts demonstrates the variation in payment rates among payer sources. The practical implications demonstrate the provider challenges in managing patient mix to maintain a viable practice.
本研究评估了2013年公布的德克萨斯州医疗保险和医疗补助计划的医生报销费率，并将这些费率与私人保险公司的平均费用进行了比较。医生索赔数据取自Truven MarketScan商业索赔数据库。编制了每个程序代码的单位平均允许金额。获取了2013年医疗保险医生费用表并筛选到德克萨斯州。获取了2013年德克萨斯州医疗补助计划医生费用表。按单位费率将商业允许平均金额与医疗保险和医疗补助计划的金额进行比较。得出每个代码的比较比率。然后将CPT©程序代码分组到美国医学协会指定的类别中。私人/医疗保险和私人/医疗补助的比率因程序类型和地区而异，德克萨斯州医疗补助费用远低于私人和医疗保险费用。支付金额的差异表明了支付方来源之间支付费率的差异。实际影响表明了提供者在管理患者组合以维持可行业务方面面临的挑战。
