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Private Payers Pay More than Medicaid for E&M Services

A recently released Government Accountability Office (GAO) study found that providers receive lower reimbursement rates from Medicaid than from private insurers for evaluation and management (E&M) services. The study compared payment rates of private payers against both Medicaid fee-for-service (FFS) and managed care models for 26 E&M codes. Claims analysis of these codes showed that private payers reimburse at higher rates than Medicaid for all care settings studied – office visits, hospital care, and emergency care. GAO found that providers are paid 27 to 65 percent less through Medicaid FFS than through private insurance in 31 of the 40 states studied. Further, of the 23 states in which Medicaid managed care reimbursement was analyzed, providers in 18 states received payments that were 31 to 65 percent lower through Medicaid managed care than through private reimbursement. The study was conducted using data that did not include the temporary increases in Medicaid reimbursement, which are set to expire at the end of 2014.

Please contact Xiaoyi Huang, JD, director of policy, at xhuang@essentialhospitals.org or 202.585.0127 with questions.

 

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About the Author

Matt Buechner is the policy and advocacy associate for America's Essential Hospitals.

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