Private Carriers' Physician Payment Rates Compared With Medicare and Medicaid

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.