Wiki Medicare Reimbursement Question

[robgwinn]

Does anyone know if there is a "rule" out there that states that Commercial payers "must" have higher allowables for fees than Medicare?

There's been some debate here in our office.

Any help would be appreciated..

Thanks!

 

[cobrapam]

Medicare

My understanding is there is not a "rule" for higher reimbursement from commercial payers vs. Medicare.

Most commercial payers fall in line with what Medicare allows and use that as a base. Some will pay a percentage over that, but most reimbursement with commercial payers is based on your In-Network Contract with that specific payer.

If you are out-of-network it is usually based on Reasonable and Customary for that procedure/service. Which is usually based on Medicare allowable.