MGMA survey highlights reimbursement disparities

Practices reported lower actual payment rates than those contracted for nine of the 10 common CPT codes examined.

By Mike Norbut, AMNews staff. Aug. 9, 2004.

Physician practices in Colorado that know their contracted reimbursement rates receive on average 4.5% more for a standard office visit than practices that don't know their rates, according to a recent survey by the Medical Group Management Assn.

The survey, which compiled information from 51 practices across the state, not only uncovers the disparities some physicians find between contracted and actual reimbursement rates, but it also highlights the idea that some doctors don't know what should be coming to them.

Many of the respondents to the survey were tracking their reimbursements based on their explanation of benefit statements from insurers rather than their contracts.

"What's a little disappointing is the number of practices that didn't have specific payment rates," said William F. Jessee, MD, president and CEO of MGMA. "We've been advising our members to regularly audit their EOBs, but you can't do that if your insurer doesn't give you the fee schedule."

Jeremy A. Lazarus, MD, vice speaker of the AMA House of Delegates, said the AMA considers the disparities between contracted and actual reimbursement rates to be a "systemic" issue, a result of insurers' claims processing and payment systems.

"This reduction in payment to physicians is a direct consequence of the unfair business practices of health plans that include downcoding and bundling of physician claims, as well as delayed, partial paid and retroactively denied payments to physicians," said Dr. Lazarus, a psychiatrist from Greenwood Village, Colo.