Trends in Medicare Submitted Charges to Allowed Payment Ratios for Ophthalmology Services

Abstract

Purpose

Many physicians charge more than the Medicare insurance program pays. Current charge-to-payment ratios in ophthalmology and trends over the years are unknown. In this work, we examined physician charge-to-payment ratios in ophthalmology across procedures and consultations.

Methods

We utilized data from 100% final-action physician/supplier Part B Medicare fee-for-service (FFS) population from 2015 to 2020. We retrieved data on ophthalmic procedures and consultations, both facility-based and non-facility-based, conducted by ≥ 50 ophthalmologists. We analyzed median charge-to-payment ratios, which were calculated as submitted charges divided by the Medicare-allowed payments, between ophthalmic procedures and consultations to assess for trends over the study period.

Results

We find that the median charge-to-payment ratio for all current procedural terminology (CPT) codes in 2020 was 2.23 (Interquartile range (IQR): 1.54–3.27) as compared to 2.00 (IQR: 1.39–2.92) in 2015, an overall 2.76% average annual growth rate from 2015–2020. For ophthalmic procedures, the median charge-to-payment ratio in 2020 was 3.03 (IQR: 2.13–4.41) compared to 2.79 (IQR: 1.96–3.97) in 2015, corresponding to a 2.01% AAGR from 2015–2020. For consultations, those rates were 2.06 (IQR: 1.48–2.96), 1.85 (IQR: 1.33–2.59), and 2.71%, respectively.

Conclusion

We found that the submitted charge-to-Medicare payment ratios among ophthalmic procedures and consultations have steadily increased since 2015. However, there was a relatively low rate of excess charges for ophthalmology services compared to other surgical-based specialties with minimal variation among providers.

Keywords:

• medicare excess charge
• ophthalmology services
• billing
• trends
• allowed medicare payments

Disclosure

The authors report no conflicts of interest in this work.

Additional information

Funding

There is no funding to report.