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Medicare vs private reimbursement rates

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  • Medicare vs private reimbursement rates

    I am joining a large outpatient private practice group in September. My payor mix should be around 50/50 Medicare/private. No Medicaid.

    It looks like the CMS reimbursement for 99214 (established 4 E/M) is about ~$125 in my area. Does anyone have a sense of what a private payer would pay for a 99214 as an example? Is it the same rate, 120%, 150%, or 200%? I'm joining a large private group that has ~200 offices in 20 states. I understand these are privately negotiated rates, but I'm wondering if I can get some estimates or general feedback from docs who are currently practicing.

    Thank you

  • #2
    For me, commercial E&M reimbursement is about 20% more than medicare. Procedure codes are a much larger difference, 50-120% higher than Medicare depending on the procedure.


    • #3
      We've been gaining a lot higher on the commercial products, but we're an academic institution and tend to be 'expensive' rates - which is true across the board.