Medicare Physician Reimbursement
Physicians are reimbursed for covered services by Medicare and many other payers based on a standardized payment schedule that accounts for the resource (cost) required to provide the service. This reimbursement methodology is referred to as the resource-based relative value scale (RBRVS) system, which divides physician services into three cost components:
- Physician work: the time spent by the physician to provide the service.
- Practice expense: the costs of operating the physician practice.
- Professional liability (malpractice) insurance.
Through our many years of experience working with physician reimbursement systems, Myers and Stauffer can help government-sponsored health care programs develop or update an RBRVS reimbursement system or methodology. Our experience includes developing state-specific reimbursement amounts and components of the reimbursement methodology, such as conversion factors and site of service payment differential, and assisting states in determining the physician upper payment limit (UPL) for physician supplemental payments.
Rate Setting and Reimbursement
Jared Duzan, CFE
Myers and Stauffer assists our government-sponsored health care clients with the development of accurate, equitable, and transparent reimbursement rates for physician services. This includes physician services, non-physician practitioner services, and physician administered drugs. Our expertise includes:
- Policy and benefit analysis.
- Rate adequacy studies.
- Developing fee schedule rates.
- Developing policy adjustors based on the level of practitioner or service modifier.
- Updating components of the RBRVS system such as conversion factors.
- Developing and implementing alternative payment model (APM) strategies.
- Data analytics and dashboards.
- Implementation assistance.
- Socialization planning.
- State plan/regulation amendments.
Medicaid Financing and Reporting
Tim Guerrant, CPA
Many states provide additional reimbursement, typically in the form of supplemental payments, to physicians associated with academic teaching institutions. These programs require an understanding of Medicaid, Medicare, and commercial insurer physician reimbursement and federal requirements pertaining to limits on Medicaid physician supplemental payments. Our Medicaid financing team assists state Medicaid agencies with physician payment programs, including:
- Supplemental payment program design and oversight.
- Value-based payment (VBP) strategies.
- Federal UPL compliance.
- Fiscal impact estimates.
Ryan Farrell, CFE
Through our benefit/program integrity services, Myers and Stauffer is able to assist our government health care clients with their review of physician claims to ensure provider payments are made in accordance with applicable state regulations and policies. Our services focus on the adequacy of documentation and the accurate coding of services. We review claims for physician administered drugs for compliance with applicable policies. In additional to general practitioners (family and internal medicine), we also review all specialty categories, including but not limited to: pediatrics, oncology, OB/GYN, and emergency. Our program integrity services include:
- Claims analysis.
- Post-pay claims audits – clinical and financial.
- Pre-pay claims audits – clinical and financial.
- Medicaid recovery audit contractor (RAC) services.
- Software modules for surveillance and utilization review subsystem (SURS), fraud and abuse detection services (FADS), and case tracking.
- Provider compliance.
- Payment system processing accuracy.
- Fraud, waste, and abuse detection (FWAD) litigation support.
- Opioid analysis.
Managed Care Oversight and Compliance
Mike Johnson, CPA, CFE
The extensive services offered by our highly skilled managed care team are generally focused on the oversight of health plans but can impact all provider types, including physician clinics. These services include:
- Encounter data reconciliation and validation.
- Financial audits, performance audits, and program effectiveness audits.
- Network adequacy assessments and member access compliance.
- Readiness reviews.
- Claims payment and denial assessments, accuracy, and timeliness.
- Medical record review.
- Grievance and appeals analysis.
- Contract compliance.
- Other provider-specific issue review and resolution activities.