Conduff Joseph H, Coelho Daniel H
Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia.
Otol Neurotol. 2017 Aug;38(7):985-989. doi: 10.1097/MAO.0000000000001476.
Medicaid reimbursement rates for cochlear implants and related services fall short of the federal benchmark set by Medicare.
The financial hardships of cochlear implant centers around the United States may be a repercussion of poor Medicaid reimbursement. In time, these reimbursement discrepancies could force additional Otolaryngologists and cochlear implant centers to not provide these crucial services due to financial limitations.
Based on Medicare (MCR) claims data, current procedural terminology (CPT) codes used for cochlear implantation and related services were selected. Medicaid (MCD) and Medicare (MCR) payment schemes were queried for the same services in 49 states and Washington, D.C. The difference in MCD and MCR payment in dollars and percent was determined and reimbursement per relative value of work (RVU) calculated. MCD reimbursement differences (by dollar amount and by percentage) were qualified as a shortfall or excess as compared with the MCR benchmark.
Marked differences in MCD and MCR reimbursement exist for all cochlear implant related services, most commonly as a substantial shortfall. The MCD shortfall varied in amount between states and great variability in reimbursement exists within and between audiology, surgery, and speech services. Shortfalls and excesses were not consistent between procedures or states.
The variation in MCD payment models reflects marked differences in the value of the same work provided, which in many cases is far less than federal benchmarks. These results question the fairness of the MCD reimbursement scheme in cochlear implantation with potential serious implications on access to care for this underserved patient population.
医疗补助计划（Medicaid）对人工耳蜗植入及相关服务的报销率低于医疗保险（Medicare）设定的联邦基准。
美国各地人工耳蜗植入中心面临的经济困难可能是医疗补助计划报销不力的后果。随着时间的推移，这些报销差异可能会迫使更多的耳鼻喉科医生和人工耳蜗植入中心因经济限制而不再提供这些关键服务。
基于医疗保险（MCR）理赔数据，选择用于人工耳蜗植入及相关服务的当前程序编码术语（CPT）代码。查询了49个州和华盛顿特区针对相同服务的医疗补助计划（MCD）和医疗保险（MCR）支付方案。确定了MCD和MCR支付在美元和百分比方面的差异，并计算了每项工作相对价值单位（RVU）的报销金额。将MCD报销差异（按金额和百分比）与MCR基准相比，确定为不足或超额。
所有人工耳蜗植入相关服务的MCD和MCR报销存在显著差异，最常见的是大幅不足。MCD不足金额因州而异，听力学、手术和言语服务内部及之间的报销差异很大。不同程序或州之间的不足和超额情况并不一致。
MCD支付模式的差异反映了相同工作价值的显著差异，在许多情况下，其价值远低于联邦基准。这些结果质疑了MCD在人工耳蜗植入报销方案的公平性，可能对这一服务不足患者群体获得医疗服务产生严重影响。
