Ghaith Summer, Ginsberg Zachary, Pollock Jordan, Rappaport Douglas
Emergency Medicine, Mayo Clinic, Phoenix, USA.
Emergency Medicine, Mayo Clinic Alix School of Medicine, Phoenix, USA.
Cureus. 2024 Jul 17;16(7):e64755. doi: 10.7759/cureus.64755. eCollection 2024 Jul.
As the Medicare population continues to grow, financial pressure is placed upon hospitals, physicians, and other providers as the payer mix has an increasing proportion of Medicare patients.
The purpose of this study was to further the understanding of reimbursement trends surrounding the five levels of emergency department (ED) examinations (CPT codes 99281-99285) from 2010 to 2018 and determine how they have changed with respect to each procedure.
CPT codes were filtered into the 2010 and 2018 Physician/Supplier Procedure Summaries from the Centers for Medicare and Medicaid Services' website to gather data on emergency physician submissions and Medicare denials and payments.
In 2010, 15,669,196 ED examinations were submitted to Medicare for $7,628,693,382 while in 2018, 16,432,184 ED examinations were submitted for $14,522,456,383. Despite an increase of $397/submission made by emergency physicians, Medicare paid 20.5% of the submitted charges in 2010 for ED examinations and 11.9% in 2018. The denial rate in 2018 was highest for level I ED examinations (11.3%), and the lowest for level V examinations (5.1%). The utilization of level V ED examinations increased 22.3% from 2010 to 2018, while the utilization of the others decreased. Of the five levels of ED examinations, only the level I examination did not exhibit a decrease.
From 2010 to 2018, emergency physicians charged a higher amount for ED examinations, yet Medicare reimbursement accounted for a smaller proportion of these charges, resulting in less payment per submission for the four most common levels. Downward trends in Medicare reimbursement may place financial burdens that could potentially hamper healthcare outcomes.
随着医疗保险覆盖人群持续增长，由于医保患者在支付方组合中的比例不断增加，医院、医生及其他医疗服务提供者面临着财务压力。
本研究旨在进一步了解2010年至2018年围绕急诊科（ED）五级检查（现行程序编码99281 - 99285）的报销趋势，并确定各项程序的变化情况。
从医疗保险和医疗补助服务中心网站的2010年和2018年医生/供应商程序汇总中筛选现行程序编码，以收集急诊医生提交的申请、医疗保险拒付及支付的数据。
2010年，向医疗保险提交了15,669,196次ED检查申请，金额为7,628,693,382美元；2018年，提交了16,432,184次ED检查申请，金额为14,522,456,383美元。尽管急诊医生每次申请的收费增加了397美元，但医疗保险在2010年为ED检查支付了所提交费用的20.5%，2018年为11.9%。2018年，I级ED检查的拒付率最高（11.3%），V级检查的拒付率最低（5.1%）。从2010年到2018年，V级ED检查的使用率增加了22.3%，而其他级别检查的使用率下降。在ED检查的五个级别中，只有I级检查使用率未下降。
从2010年到2018年，急诊医生对ED检查的收费更高，但医疗保险报销在这些费用中所占比例更小，导致四个最常见级别的每次申请支付金额减少。医疗保险报销的下降趋势可能带来财务负担，进而可能影响医疗保健结果。
