What Are Medicare Reimbursement Rates ?

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.

Doctor reviews information with patient

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 2018 Alpha-Numeric HCPCS File from the CMS website. 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.

Did you know that depending on your health care needs, you could potentially save money on some of your health care costs by joining a Medicare Advantage plan? Contact a licensed insurance agent to learn more and to compare plans available in your area by calling TTY Users: 711 24 hours a day, 7 days a week.  

 

1 Centers for Medicare and Medicaid Services. How to Use the Searchable Medicare Physician Fee Schedule (MPFS). (Jan. 2016). Retrieved from www.cms.gov/apps/physician-fee-schedule/help/How_to_MPFS_Booklet_ICN901344.pdf.

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