Reimbursement Issues

Question

Answer

1. HOSPITAL AUDIOLOGY REIMBURSEMENT. Medicare rates are governed by the hospital Outpatient Prospective Payment System (OPPS). Attached is a description and the actual rates for each CPT code. You may know that Medicare reimburses for diagnostic tests only and the scope of coverage is rather narrow. Medicare payment for services to inpatients is all-inclusive within a PPS rate per patient stay. Each state's Medicaid program is different. Outpatient rates may or may not be similar to the Medicare rates. The Medicare Physician Fee Schedule (website indicated below) governs all outpatient rates except in hospital clinics (OPPS).

2. FLAT-FEE OUTPATIENT CLINIC RATES. This payment mechanism is used by various state Medicaid programs. Some states contract with specific hospitals for a single payment per outpatient ''day.'' Others establish a fee for each separate visit (to separate specialties).

3. TYPICAL RATES. For Medicaid, we have seen a wide range of rates for the same procedure. In some states, all of the Medicaid rates are low; in other states some procedures are outrageously low while others are even higher than the Medicare rate. You can use the Medicare Physician Fee Schedule as a point of reference. See ASHA's website at: https://www.asha.org/Practice/reimbursement/medicare/Overview-of-the-Medicare-Physician-Fee-Schedule/.

4. STRATEGIES FOR RAISING (MEDICAID) OUTPATIENT FLAT FEE RATES. Common combinations of CPT codes that represent a state's flat fee outpatient episode should be compared to the total payment for the same codes when calculated using the Medicare Physician Fee Schedule. Any outpatient episodes that pay significantly lower than the Medicare rate should be addressed as unreasonable, considering that Medicare fees are below market rates. It may also be useful to collect and compare Medicaid payment rates from neighboring states. The following weblink provides a list of phones numbers for the Office of the Director of each state Medicaid plan: https://medicaid.aphsa.org/content/APHSA/en/home.html

5. WHEN IS A MEDICAID PIN NUMBER NECESSARY IN A HOSPITAL CLINIC? Each state Medicaid program may have varied requirements, though the usual protocol is for each professional practitioner to be assigned a provider identification number. In some states, the hospital clinic identification number may be sufficient.



Mark Kander
Director
Health Care Regulatory Analysis
American Speech-Language-Hearing Association
10801 Rockville Pike
Rockville, MD 20852
301/897-0139 fax 301/897-7356
800/498-2071 x4139
Mkander@asha.org