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Medicare Reimbursement Question

  1. #1
    Question Medicare Reimbursement Question
    Medical Coding Books
    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..


  2. #2
    Default 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.

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