Typical Charges for 20% of Outpatient Services

Nov 7, 2015

  1. AOKING
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    AOKING Super Genius

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    Here in my area, 2 of the three UHC MAPDS have a 20% Co ins for outpatient services. Just curious what that average copay could be.....is that 20% of the allowed amount on Medicare's schedule?
    Thanks for the help.
    Ao
     
    AOKING, Nov 7, 2015
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  2. somarco
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    somarco That Medicare Expert Guy

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  3. AOKING
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    AOKING Super Genius

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    Thank you. What a great service.
     
    AOKING, Nov 7, 2015
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  4. somarco
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    somarco That Medicare Expert Guy

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    You are welcome. Tips greatly appreciated.
     
    somarco, Nov 7, 2015
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  5. saintstigers
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    saintstigers Guru

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  6. yogooglethis
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    yogooglethis Guru

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    good app if you want to be very very conservative on pricing but Medicare allowable rates are usually much less

    for example:

    Cataract Surgery according to blue book

    Total Fair Price:$3,559
    20% would be 711.18



    20% allowable charges on medicare typically about 300-400.00

    20% MA contracted rate typicallly about 200-300
     
  7. MBSC
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    MBSC Expert

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    Exactly. Healthcare Bluebook provides a competitive billed charge. MADP use the lower Medicare fee schedule allowed amounts as a starting point and then negotiates with providers for even lower allowed amounts further reducing co-insurance.
     
    MBSC, Nov 8, 2015
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  8. somarco
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    somarco That Medicare Expert Guy

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    Certainly no reason to use a resource like the bluebook when you can always just SWAG it. Good luck with that approach.

    Personally, I never tell a client what their charges/OOP might be on a particular claim. If they press, I refer them to the bluebook. If their OOP is higher they can't pin it on me.

    40 years without an E&O claim. No reason to start now.
     
    somarco, Nov 8, 2015
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  9. yogooglethis
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    Not a good idea to mention co insurance prices at all to consumers but I thought this was a forum for agents to talk shop.i thought the OP might be interested in the factoid that medicare part b allowable charges are usually way lower than commercial health insurance and that MA negotiated charges are usually even lower



    you can search what was how much was paid for each service by physician here.

    Medicare Unmasked: Behind the Numbers - WSJ.com
     
  10. somarco
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    somarco That Medicare Expert Guy

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    This was news to me so I asked a MOM about this phenomena. Her response.



    When Medicare Advantage plans started, they were set up without contractual obligations on the part of the provider and promised to pay Medicare rates. My experience with Medicare Advantage plans is that they pay as well or better than Medicare. Since they are non-contractual, if they do not pay the same rates, then doctors should not see the patients.

    Also, Advantage plans, being commercial, do not have the regulations that Medicare plans have. For example, only a Physical Therapist can bill Medicare for Message Therapy, and it cannot be billed incident to. In Advantage plans, a mid level, massage therapist, can bill for Massage Therapy incident to a physician.

    As to your question, MA should not be paying less than Medicare and if the plan is then the doctor should review his charges to ensure that he is charging the Medicare rate or higher. If his charges are correct, then drop that MA patient.
     
    somarco, Nov 10, 2015
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