New Fee Survey: Bridging the reimbursement gap

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Our latest survey on fees and reimbursements shows a continuing--and substantial--gap between what you charge and what you get paid.


Cover Story


Bridging the reimbursement gap

Jump to:Choose article section...How practice size affects feesWhat doctors in 10 fields charge for office visitsFees are also affected by . . . Internists lose ground; FPs gain Typical charges and reimbursements in five specialties Physicians receive no extra reimbursement for hospital care

Our latest survey on fees and reimbursements shows a continuing—and substantial— gap between what you charge and what you get paid.

By Wayne J. Guglielmo
Senior Editor

Where do you think reimbursements are heading?

The formula might as well be set in stone: Once again this year, as for the past several years, primary care physicians report getting paid about 75 percent of their charges for office visits. Physicians overall get paid less than 50 percent for most major CPT procedures and services, according to the results of the latest Medical Economics Continuing Survey of MDs and DOs in office-based private practice.

Overall, primary care physicians raised median office visit fees in all 10 CPT codes by an average of 7.5 percent, or $6.80. Although reimbursements nearly matched the percentage increase at 7.3 percent, that $5.60 wasn't nearly enough to close the fee-reimbursement gap.

GPs were the most aggressive of the primary care group, raising their median office-visit fees an average of $11.10 per visit. But their reimbursements went up by only $8.10.

General internists, who posted the lowest dollar increase among primary care physicians, raised their office visit fees by an average of just $4.70, and actually dropped their fees for CPT codes 99201 and 99211, level 1 visits for new and established patients. Reimbursements increased $6.50 on average.


The picture for procedures was a mixed bag for internists. Median fees for sigmoidoscopies rose by $11, or 6 percent, while reimbursements remained flat at $100. Internists saw both their median fee and reimbursement for ECGs drop, by 8 percent and 6 percent, respectively.

Family physicians are narrowing the gap between themselves and general internists in office visit charges. This year, FPs raised median office-visit fees by $7.10 on average, with the biggest increases in codes 99204 (up $19) and 99205 (up $18). With these increases, fees for FP office visits are now only $5.50 less on average than internists' charges.

As for procedures, FPs get even more than internists for at least one common office procedure—sigmoidoscopy. This year, they raised their median fee to $200, a 20 percent increase over 2001. In return, they receive $110—$10 more than the typical internist and gastroenterologist get paid.

It was a mixed bag for cardiologists this year, too. On the one hand, the median fee increases they took in six out of 10 office-visit codes were almost entirely matched in reimbursement increases. On the other hand, their average fee increase of $25 for the five procedures we tracked was offset by a $15.20 loss in reimbursements. Despite a $100 increase in the median fee for left-heart catheterization, for example, they actually got back $41 less from insurers.

Gastroenterologists did better in 2002 on office visits. They raised their fees an average of $3.30, but saw a robust increase in reimbursements of $4.70. For CPT codes 99203 and 99205, fees remained flat, but reimbursements were up $4 and $10, respectively. Reimbursements also increased by $10 for sigmoidoscopies.

The news wasn't as good on several other procedures, though. The median fees for upper GI endoscopy increased by $25, but actual payment fell $20. Similarly, gastroenterologists raised their fees for liver biopsy by $12, but their reimbursements dipped by the same amount. Both fees and reimbursement for dilation of the esophagus remained unchanged.

Pediatricians had bad news and good. They raised median office fees by $7, but saw only $4.70 of that returned. There was no substantial increase in reimbursements for hospital visits. Pediatricians did slightly better on most procedures, and especially well on circumcisions. Their circumcision fees rose 20 percent, while reimbursement rose a healthy 45 percent.

Ob/gyns, on the other hand, kept their median fee for circumcision the same, while reimbursement rose 10 percent. Ob/gyns now receive $35 less than pediatricians for the same procedure.

Ob/gyns did see a $5 return on their fee increase of $4.70 for office visits, though. For the eight procedures for which we have comparable data, they saw almost no change at all (–0.4 percent) in reimbursements over last year.

Median office-visit fees for general surgeons also remained virtually flat this year, while their reimbursements rose by an average 8.8 percent. For the eight procedural codes for which we have comparable data, the average fee increase was 6.3 percent, while reimbursements went up 8.5 percent.

The picture was less bright for orthopedic surgeons. Their office-visit fees were up $2.90 or 5.4 percent, but reimbursements decreased by 89 cents. For the seven procedural codes we tracked, they gained about 4 percent on the fee side and about 2 percent on the payment side.

How can doctors cope in this precarious economic environment?

"Since managed care payments can vary by more than 20 percent per plan, well run practices have begun reviewing what each plan pays and deselecting those that don't make the grade," says Michael Wiley, a practice-management consultant from Bay Shore, NY. Wiley also recommends that doctors increase their fees, "avoiding the chance they're charging less than an insurance company would have paid," he explains.

That was the strategy used by internist Scott P. Rigby, of Munroe Falls, OH, when he discovered his nine-member group was missing out on a quarter of a million dollars because of a poorly calibrated fee structure. Says Rigby: "Calculating maximum reimbursement, I realized, was the key to increasing our revenue—without requiring any of the partners to see more patients, work longer hours, or take less vacation. Basically, this was lost money waiting to be found. And I found it." (See "We're not leaving $250,000 on the table anymore," Sept. 9, 2002. )

How do your fees and reimbursements compare to those of your colleagues in the same specialty, region, and practice size? The accompanying tables will help you pinpoint that.


How practice size affects fees

 New patient (99204)Established patient (99213)
FeeActual paymentFeeActual payment
Solo practice$145$100$65$47
2 doctors1451086046
3 doctors1401056550
4 doctors1501077048
5-9 doctors1521086548
10-24 doctors1631086549
25-49 doctors1381007549
50 doctors or more1861347550
Doctors in single-specialty groups1501076549
Doctors in multispecialty groups1601106848
Doctors in salaried groups1551146550



What doctors in 10 fields charge for office visits

 New patient
FeeActual paymentFeeActual paymentFeeActual paymentFeeActual paymentFeeActual payment
Cardiologists (invasive)$70$35$95$61$125$90$175$124$225$160
Cardiologists (noninvasive)6036856012590165125202150
General surgeons5638755710580148110195140
Orthopedic surgeons6539906012084160110220150
All primary care5540785810380145103180133


 New patient
FeeActual paymentFeeActual paymentFeeActual paymentFeeActual paymentFeeActual payment
Cardiologists (invasive)$32$19$50$35$70$50$100$75$150$110
Cardiologists (noninvasive)35235235705010075150102
General surgeons3522503566489371140100
Orthopedic surgeons38255234714810072145100
All primary care3220503565489270130100



Fees are also affected by . . .

 New patient (99204)Established patient (99213)
FeeActual paymentFeeActual payment
Inner city$150$100$67$45


Internists lose ground; FPs gain

 InternistsCardiologists (invasive)Cardiologists (noninvasive)
Median fee (change since 2001)$55 (–8%)$60 (–8%)$60 (–8%)
Median reimbursement (change since 2001)30 (–6%)27 (–7%)29 (–9%)
Median fee (change since 2001)$186 (+6%)$200 (+20%)$200 (no change)
Median reimbursement (change since 2001)100 (no change)110*100 (+11%)



Typical charges and reimbursements in five specialties

 Fee (change since 2001)Actual payment (change since 2001)
History & examination of normal newborn (99431)$150 (+3%)$97 (–3%)
Immunization, DTaP (90700)35 (no change)25 (+9%)
MMR virus vaccine, live (90707)50 (no change)38 (+6%)
Circumcision, clamp, newborn (54150)180 (+20%)145 (+45%)
Circumcision, clamp, newborn (54150)$200 (no change)$110 (+10%)
Total hysterectomy, abdominal (58150)2,525 (–3%)1,190 (–1%)
Complete OB care, routine, vaginal delivery (59400)2,500 (no change)1,774 (+4%)
Complete OB care, routine, w/cesarean section (59510)3,000 (+4%)1,897 (+5%)
Dilation & curettage, diagnostic and/or therapeutic (non-ob) (58120)650 (–5%)300 (+5%)
Induced abortion, by dilation & curettage (59840)708 (–6%)315 (–10%)
Dilation & evacuation for induced abortion, by (59841)800 (–1%)4002
Laparoscopy, surgical, with fulguration of oviducts (58670)1,300 (+5%)500 (–12%)
Colposcopy (vaginoscopy); LEEP (57460)669 (+3%)250 (–4%)
Upper gastrointestinal endoscopy, diagnostic (43235)$525 (+5%)$200 (–9%)
Liver biopsy, needle; percutaneous (47000*)1312 (+4%)138 (–8%)
Dilation of esophagus, by unguided sound or bougiesingle or multiple passes (43450*)1200 (no change)100 (no change)
Total hysterectomy, abdominal (58150)$2,4002$1,0462
Appendectomy (44950)1,300 (+8%)600 (+5%)
Laparoscopy, surgical; appendectomy (44970)1,450 (+2%)640 (+7%)
Cholecystectomy (47600)1,918 (+1%)895 (+12%)
Laparoscopy, surgical; cholecystectomy (47562)2,400 (+3%)868 (+2%)
Initial inguinal hernia repair, age 5 or over; reducible (49505)1,200 (+7%)550 (+16%)
Gastrectomy/partial, distal—with gastroduodenostomy (43631)2,750 (+10%)1,250 (+14%)
Modified radical mastectomy (19240)2,385 (+8%)1,000 (no change)
Excision of cyst or fibroadenoma frombreast tissue, one or more lesions (19120)798 (+11%)391 (+12%)
Colles’ fracture, closed manipulation (25605)$750 (no change)$450 (+12%)
Open treatment of hip fracture (27244)3,000 (+9%)1,171 (–3%)
Knee arthroscopy with meniscectomy (29881)2,265 (+1%)900 (+8%)
Total hip arthroplasty (27130)4,778 (+5%)1,600 (–6%)
Diagnostic knee arthroscopy (29870)1,118 (+5%)523 (+10%)
Total knee arthroplasty (27447)4,677 (–4%)1,700 (–6%)
Arthrocentesis of knee (20610*)1115 (+15%)65 (no change)


Physicians receive no extra reimbursement for hospital care

FeeActual paymentFeeActual paymentFeeActual payment
FeeActual paymentFeeActual paymentFeeActual payment


How cardiologists are doing

Median fee (change since 2001)$400 (no change)
Median reimbursement (change since 2001)190 (–11%)
Median fee (change since 2001)$500 (no change)
Median reimbursement(change since 2001)152 (+1%)
Median fee (change since 2001)$900 (+12%)
Median reimbursement (change since 2001)259 (–14%)
Median fee (change since 2001)$275 (+10%)
Median reimbursement (change since 2001)47*
Median fee (change since 2001)$200 (no change)
Median reimbursement (change since 2001)31 (–31%)


A Medical Economics Web exclusive

Office-visit fees around the country

 FeeActual PaymentFeeActual PaymentFeeActual PaymentFeeActual Payment
General internists**150*****
All respondents15095145105145111160118
General internists**7145****
All respondents6848654661497050


How this year's fee survey was conducted

Questionnaires for this year's Medical Economics Continuing Survey were mailed in late May to 32,450 MDs and DOs in private, office-based practice throughout the US. This represents a random sampling of 9 selected specialties from the AMA master list maintained by Access Worldwide-the Phoenix Marketing Group.

By the early August cutoff date, 4,055 MDs and DOs had responded. After we set aside returns with apparent discrepancies and those from physicians who hadn't been providing office-based patient care in 2002, our working sample consisted of 2,614 physicians. These were coded by Medical Economics Research services' staff and then tabulated by Suzane Coopersmith of Crosstabs, Inc., in Syosset, NY.

The survey sample was selected so as to be representative within each specialty as to type of practice, age, geographical region, and gender. The results were weighted to reflect these criteria.

The survey was developed and fielded under the direction of Sandy Johnson, Manager of Field Services.


Wayne Guglielmo. New Fee Survey: Bridging the reimbursement gap. Medical Economics 2002;21.