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What Are Medicare Reimbursement Rates?

Medicare reimburses health care providers for services and devices they provide to beneficiaries. Learn more about Medicare reimbursement rates and how they may affect you.

Medicare reimbursement rates refer to the amount of money that Medicare pays to doctors and other health care providers when they provide medical services to a Medicare beneficiary.

The Medicare reimbursement rate is also referred to by Medicare as the Medicare Physician Fee Schedule (MPFS). The payment schedule varies according to the service or item that is provided, along with additional factors such as the type of health care provider involved.

What is the Medicare rate of reimbursement?

The rate at which Medicare reimburses health care providers is generally less than the amount billed or the amount that a private insurance company might pay. According to the Centers for Medicare & Medicaid Services (CMS), Medicare’s reimbursement rate on average is roughly 80 percent of the total bill.1

Not all types of health care providers are reimbursed at the same rate. For example, clinical nurse specialists are reimbursed at 85% for most services, while clinical social workers receive 75%.1

Viewing Medicare reimbursement rates

Medicare uses a coded number system to identify health care services and items for reimbursement. The codes are part of what’s called the Healthcare Common Procedure Coding System (HCPCS).

To view current Medicare reimbursement rates for certain health care services, you’ll need two things:

  1. The HCPCS code of the service or item being reimbursed
  2. The searchable Medicare Physician Fee Schedule (MPFS)

HCPCS codes can be viewed by downloading the most recent Alpha-Numeric HCPCS File from the CMS website. These HCPCS quarterly updates are published roughly every four months.

The HCPCS code will also typically appear on your bill from the health care provider.

The searchable Medicare Physician Fee Schedule can also be accessed on the federal Medicare website. Enter the HCPCS code in the box provided and click “Submit” to see the rate at which Medicare reimburses for the given service or item.

Learn more in the CMS guide How to Use the Searchable Medicare Physician Fee Schedule.

Using HCPCS codes

It’s a good idea for Medicare beneficiaries to review the HCPCS codes on their bill after receiving a service or item. Medicare fraud does happen, and reviewing Medicare reimbursement rates and codes is one way to help ensure you were billed for the correct Medicare services.

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Christian

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.

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1 Centers for Medicare and Medicaid Services. (March 2021). How to Use the Searchable Medicare Physician Fee Schedule. https://www.cms.gov/files/document/physician-fee-schedule-guide.pdf.