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I am trying to advise a relative on whether to drop a Medicare Advantage plan and just have straight Medicare. They advertise that you need their plan because Medicare only pays eighty percent, but it appears that they only pay eighty percent, too. The complication is that they (like most insurers) have contracts with providers for discounts ("contractual adjustments") and they pay eighty percent of the difference.

Medicare basically does the same thing, except that instead of a contract, it’s “We decided it’s worth ____, take it or leave it." (Usually less than providers costs, which is why so many refuse Medicare patients.) So, I can see what the plan paid, but all I can predict for Medicare is that the patient responsibility will be twenty percent of the "Medicare approved amount."

I wanted to compare what their plan paid this year with what straight Medicare would have paid. I ran a search for one of the procedures they had done on a database in the Medicare website and got four different dollar amounts. I called Medicare for advice on how to interpret it, and got someone who adamantly insisted the database I was looking at didn't exist.

Can anyone here tell me somewhere I can find the "Medicare approved amount" for selected HCPCS codes? I recently retired from a large healthcare provider, and I could provide my former colleagues with SQL to answer the question, but they'd get fired (and maybe go to jail) if they run it for me (privacy laws).

With the plan, they pay medicare premium plus plan premium plus 20% of the plan adjusted bill. With medicare, they pay medicare premium plus 20% of the Medicare approved amount. Medicare approved amount is the unknown that I am trying to find.

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    A Medicare Advantage plan is roughly equivalent to plain vanilla Medicare plus what is called a Medigap policy, plus (in most cases) prescription drug coverage equivalent to or better than Medicare Part D coverage. With a Medicare Advantage plan, you pay premiums for Medicare just as you would if you had no other coverage plus premiums for the Advantage plan. Or you can pay premiums to Medicare only (plus if you like, premiums for a Medigap policy plus Part D coverage). One reason for not sticking to plain Medicare is that it does not pay for even for emergency medical treatment abroad. – Dilip Sarwate Dec 1 '15 at 4:13
  • Many Medicare Advantage policies (and the more expensive Medigap policies) do cover emergency treatment abroad plus expenses of being brought back to the US for full treatment, etc. – Dilip Sarwate Dec 1 '15 at 4:17
  • I understand that. They don't travel (I've tried to get them to go somewhere) and I have already figured out that they don't need a PDP. The question again is how to find out what patient responsibility (PR) is for (a) specific procedure(s) with "original medicare." We know exactly what the premiums are either way, and we know what PR is for the plan. We need to find out PR on original medicare so that we can find out which way total costs are lower. We have suspicions that the plan increased their costs rather than decreased. – WGroleau Dec 1 '15 at 15:49
  • I edited the question to be (hopefully) clearer. – WGroleau Dec 1 '15 at 16:07
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While I think the common user couldn't really understand this enough to use it, if you do understand HCPCS codes, you should be able to use the official CMS site:

https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

Note that there is a very specific license you have to agree to in order to use it, and you should read that carefully to ensure you have the right to use it; but it is publicly available. You have to look up individual codes one at a time, though, you're not allowed to use the API (if one exists) without a more specific license, including a license separately obtained from the AMA (which owns the physician specific terminology used).

Secondly, there is the CMS information page on Physician Fee Schedules which has several links at the bottom, one of which includes the HCPCS level file. This file may move around from time to time (as CMS reorganizes things), but it should generally be findable on their site under "Physician fee schedule".

Note that not all physicians accept Medicare Part B, and of the subset who do, not all restrict their charges to the Medicare approved rate; many will charge in excess of that (though that excess is still limited), and might only accept Medicare for part of your charges. If you want to ensure your charges are fully covered, look for a doctor that "accepts assignment" for all services - that's the terminology that describes a Medicare participating provider. See this CMS advisory page for more information.


Another option, and actually what Medicare suggests you do, is to talk to the doctor directly. They will be able to tell you ahead of time what the approved amount would have been (or more precisely, what your copay would be) - although that's subject to the specifics of the procedure, so what they really can tell you is what your copay would have been in advance (assuming nothing goes wrong that requires extra cost, basically).

  • That is the database I used, which the Medicare phone person insisted doesn't exist. Problem is that it lists four different amount for a particular HCPCS and the info PDF was no help—all it did was "explain" the search form by doing little more than repeat the labels on the form. All the doctors they go to accept assignment. And the phone person was no help because she was convinced there is no such database. In fact, she was convinced that there is no Medicare approved amount, claiming that CMS makes an individual decision on each claim after it is sent in! – WGroleau Dec 1 '15 at 17:01
  • I will check that second link, though. Might be something there that I missed. Thanks! – WGroleau Dec 1 '15 at 17:07
  • @WGroleau That's amusing. I work on a Medicare study, and it sounds like you did too, so that's extra amusing... I will say that you might be seeing amounts for different localities? On another related page to the second link, they give the zip code maps to carriers, which are related to the Medicare processing centers (MACs). It's possible that's why you see four prices, though there are quite a lot more than four of them. – Joe Dec 1 '15 at 17:16
  • The search form did ask location, but not for provider and date of service which the phone person said was needed to determine the amount. I didn't work on a study. I handled databases for a large non-profit provider (eight hospitals & many clinics), so I know how the system works, but I never knew who to contact for details like this. The different amounts were two kinds of "facility charge" and two kinds of "non-facility charge." Two terms I did not encounter on the job. I've already deleted most of the technical documentation I had for the job, and can't afford new copies. – WGroleau Dec 1 '15 at 17:57
  • @WGroleau Ah. Facility rate is the (usually higher) rate facilities are allowed to charge. I wonder - are the 2 rates 100% and 95% of each other (and the same for the other two)? 100% would be the 'assignment' rate and 95% would be the rate for non-assignment providers (who don't agree to discount their rates, so they get reimbursed 95% of the assignment rate). – Joe Dec 1 '15 at 19:57

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