Physician fees tend to be “mysterious.” Patients quite understandably go to the doctor’s office worried about the fees and expenses that will be encountered.
How do physicians set their fees? It’s important to understand–for all practical purposes, physicians do not set their actual fees or reimbursements. Medicare (the U.S. Government) every year sets a fee schedule for all Medicare patients. In the last 10 years, this fee schedule has not kept up with inflation, so fees for physicians have essentially declined over the past 10 years. Physicians and physician organizations have a small amount of input as Medicare sets fees but this input is small. Health care economists employed by the Department of Health and Human Services of the U.S. Government, in conjunction with input from the President’s Office of Management and Budget (OMB), decide Medicare reimbursement levels.
What about private insurance? Well, in the past (over 10 years ago), private insurers set their own fees, but for the past 10 years or so private insurers have essentially followed the Medicare fee schedule, usually paying the same as Medicare or a little bit more, on the order of 5 to 15% more (or sometimes even less than Medicare). If Medicare drops their fees, the private insurers follow Medicare and drop their fees.
So, in essence, physician fees are set by the U.S. Government.
Now, most physicians will have a “list price” fee but they essentially never receive this fee. Most physicians simply double the Medicare fee for a procedure or visit and call that their “list price” fee. The “list price” fee only comes into play in a few large academic medical centers in cities like Houston or New York that see wealthy patients from outside the U.S. who come to the U.S. for health care; these are essentially the only patients who pay the “list price” fee. In our office the “list price” fee is 1.5x (not 2x) the Medicare fee.
Click on this link for the Medicare fee schedule. The schedule is organized by “codes.” The coding system is confusing and opaque (doctors don’t like it but that is the system that is imposed upon us). Listed below are the codes most commonly used in our office. Pick a code and search for it in the Medicare fee schedule; the second column or “Par Fee” is the appropriate fee.
New patient consultation visit 99244
Return visit 92014 or 99213
Retinal photo 99250
Retinal angiogram (one eye) 92235
Retinal thickness map (OCT; one eye) 92135
Detailed retinal exam (one eye) 92225
Intraocular injection of medicine (most often for wet macular degeneration) 67028
Subtenons or “under the skin layer of the eye” injection of medicine 67515
Scatter or “PRP” laser for diabetic retinopathy 67228
Focal or grid laser treatment for retinal swelling or edema 67210
“Tack down” laser for retinal tear 67145
Pneumatic retinopexy (“in office repair”) of retinal detachment 67110 and 67101
Scleral buckle surgery for retinal detachment 67107
Vitrectomy surgery for retinal detachment 67108
Vitrectomy surgery for macular pucker 67041
Vitrectomy surgery for vitreous hemorrhage 67040
Vitrectomy surgery for macular hole 67042
Vitrectomy surgery for complicated retinal detachment 67113
Patients without insurance who pay their own way or are “self pay” are simply charged the Medicare fee.