Medicare Fee Schedule

By: Lewis Mark
Published: Tuesday, July 24 2018
Last Updated: 3 years ago

At the end of each year, many healthcare providers and suppliers from physicians to clinical laboratory services look out for the Medicare fee schedule. The following sections shed some light on what this fee schedule is in addition to touching on some details about Medicare reimbursement.

What Is The Medicare Fee Schedule

The Medicare fee schedule is a listing of fees that Medicare uses in order to pay healthcare providers such as doctors and those in other services like ambulatory. This fee schedule is not known to have an effect on your original deductibles, premiums, etc. However, the Medicare fee schedule can change how much you pay for any services that come with a coinsurance.

Medicare Fee Schedule 2018

It took some time to finalize, but in November of 2017, the Centers for Medicare and Medicaid Services (CMS) released the last 2018 Medicare fee schedule ruling. If you wish, you can read over the fee schedule in full. Of course, there is a breakdown of all the details about the fee schedule if you are not interested in reading the entire ruling.

One of the things noted was that the CMS finalized the means to separately code and pay for biological biosimilar products that are found under Medicare Part B. This was done in an effort to maintain professional competition as well as encourage price and availability.

Another mention was that CMS explained how they wanted E/M guidelines revised via a multi-year collaboration in an effort to improve documentation and cut back on clinical burdens.

The Medicare fee schedule for 2018 began on January 1, 2018, and it will be effective through December 31, 2018.

How Medicare Reimbursements Work

To veer off the Medicare fee schedule discussion, we take a look at Medicare reimbursement. To start: what is a Medicare reimbursement?

This is something that is applied to the payments given to physicians and hospitals based on services rendered to patients that are under Medicare. Although money travels through billing, Medicare doesn't cover the entire amount.

This type of Medicare reimbursement works differently depending on participating, non-participating, and opt-out providers. Those that participate can choose assignments at first from the Medicare fee schedule, but once they're a part of the reimbursement, then all fee schedules are accepted.

For non-participating providers, they can take in the fee schedule on a case-by-case sort of basis. Now, with opt-out providers, bypass the fee schedule and reimbursement altogether.

Participating Providers

When it comes to participating providers, they file a claim to Medicare for whatever care you have received, and the Medicare reimbursement process begins from there. As stated before, there are select providers who must partake in assignments from the fee schedule if they want to continue to accept Medicare.

Non-Participating Providers

Non-participating providers forgo accepting all assignments like providers and pick and choose what to accept instead. These types of providers will not accept Medicare as full payment, so you can be charged more for your coinsurance. However, if you were to pay-in-full, non-participating providers can still send a bill to Medicare, and you can receive a reimbursement for some of the amount.

Opt-Out Providers

Lastly, there are the opt-out providers. They do not adhere to Medicare in any way even though there are still separate rules they are mandated to follow so you can still receive fair treatment. Because of this, you must pay the entire bill after agreeing to the provider's contract.

In this case, opt-out providers don't have to worry about the Medicare fee schedule or the Medicare reimbursement plan.