Question: I am a PhD student at John Hopkins interested in studying more about health insurance reimbursement. Would you please suggest any data sources on how much hospitals charge for Holter monitors, or ambulatory electrocardiography devices, and how much hospitals get reimbursed for this item from insurance companies?
Answer 1: Managed care in the state of Maryland, where John Hopkins is located, is pretty unique because the state sets hospital rates. Hospital rate regulation in Maryland was established by an act of the Maryland legislature in 1971.
I recommend going to the Health Services Cost Review Commission (HSCRS) website. The HSCRC shares rates with the public for each hospital for each service.
This question was answered by: Caswell Samms, III, vice president of revenue cycle, St. Barnabas Hospital, Bronx, N.Y., and a member of HFMA’s Metropolitan New York Chapter.
Answer 2: Outside of Maryland, you will find that insurance payments vary greatly from state to state and even by insurer within the same state. Rates are driven by the local market. Of course, there is also the gap between Medicare and Medicaid payment and commercial insurance payments for the same service.
This question was answered by: Michele Marcum, hospital contract executive, Humana, Inc., Meridian, Idaho, and a member of HFMA’s Idaho Chapter.
Answer 3: Below are our Medicare payments for these services. The majority of payers follow the Medicare reimbursement structure based on Current Procedural Terminology (CPTs). Our charges are based on a multiple of the Medicare fee schedules below.
93224 – Holter monitor up to 48 hours, includes recording, scanning with report, review, and interpretation by physician (charge the physicians would bill):
- Physician’s Fee Schedule: $82.72
93225 – Holter monitor up to 48 hours, recording (hospital):
- Physicians’ Fee Schedule: $24.09 (no # or TC)
- National Ambulatory Payment Classification (APC): $66.52
- Local APC: $59.81
93226 – Holter monitor up to 48 hours, scanning with report (hospital):
- Physician’s Fee Schedule: $33.93 (no # or TC)
- National APC: $66.52
- Local APC: $59.81
This question was answered by: Matt Levsen, CPA, FHFMA, associate CFO, University of Missouri Health Care, Columbia, Mo., and a member of HFMA’s Show-Me of Missouri Chapter.
Do you have any additional advice related to this question? Share your views on this question—or pose another question to our Forum experts.
Publication Date: Wednesday, June 26, 2013