When you work with health insurance providers like Medicaid services, Medicare, Health Equity, or others, you must understand the fee schedules, reimbursement rates, and more to receive the correct payment rate for your medical services. Whether you work in a behavioral health nursing facility, ambulatory surgical center, primary care office, mental health facility, or any other health care or home health personal care services, you should learn about the Medicaid fee schedule for adequate billing, provider enrollment, prior authorization, and procedure code information. 

At Weave, we strive to help Medicaid providers offer seamless patient experiences that prioritize accessible care. Our comprehensive platform streamlines how modern billing and human services departments run, from collecting payments and scheduling in-person and Telehealth appointments to communicating with patients and collecting reviews. 

Read on to learn everything you need to know about the Medicaid fee schedule. 

What Is the Medicaid Fee Schedule?

A Medicaid provider fee schedule lists all fees the organization uses to compensate authorized provider services or supplies. The fee schedule includes a comprehensive list of maximum rates for physician and provider fee-for-service reimbursements. For example, if you or another physician examines a patient’s behavioral health who has Medicaid, fee schedules will help you understand the specific reimbursement information related to your exam. 

What Do I, as a Healthcare Professional, Need To Know?

As a healthcare provider, you likely make patient experiences your top priority. To provide an excellent experience, you also must focus on back-office details to ensure that you meet your patient’s health plan and benefit requirements. For example, you must chart any service you provide according to the CPT code by CPT intellectual property services to accurately inform insurance organizations of your provided care.  

Understanding rates for long-term care and service programs can be complex. We recommend reviewing the items below to better understand your options:

  • Medical assistance rate: This refers to your state’s standard reimbursement rates for any covered service. 
  • Capitated rate: This contracted rate depends on how many beneficiaries are in the specified area. 
  • Critical access hospital rate: Critical care facilities may qualify for a CAH rate if they meet certain bed numbers and average stay criteria. 
  • United States federally qualified health center rate: Centers that provide healthcare to underserved communities may qualify for specific rates or grants. 
  • Fee-for-service rate: Rather than a per-encounter all-inclusive rate, the fee-for-service model bills based on each specific service, like a blood test. 
  • Indian Health Service rate: This all-inclusive reimbursement rate bills for the entire encounter with allowables in certain states. 
  • Managed care organization rate: Managed care organizations have stricter healthcare delivery and financing controls for affordable and accountable care. Such organizations follow capitation reimbursements.  
  • Medicaid waiver rates: Your state may offer Medicaid waivers that support various healthcare services. If your patients and services meet the criteria, you may receive different fee schedule criteria funding. 

Reimbursement can vary depending on your state, fiscal year, patient population, organization, and services. Within this range, fee schedule rates will always fall within a minimum and maximum as established federally. When following provider payments under the fee-for-service model, you must consider how Medicaid reimburses the following classifications of care:

  • Inpatient hospital services
  • Outpatient hospital services
  • Physician services
  • Nursing facilities
  • Community health centers (including behavioral health services)

Whether your practice follows the American Medical Association or American Dental Association, we recommend reviewing standard reimbursement policies for the above classifications to understand the fee schedule better.

Comparing Medicare Physician Fee Schedule Differences With Medicaid

Medicare is another healthcare program, like Medicaid, that helps individuals receive coverage. Medicare specifically covers individuals over 65 or those with specific disabilities or diseases, while Medicaid supports low-income communities seeking care.  

The Medicare Shared Savings Program encourages Accountable Care Organizations to provide high-quality services to Medicare beneficiaries. You can read more about the program by reviewing the latest press release and public notice publications. 

In 2019, Medicaid fee-for-service physician service payments were 30% lower than Medicare reimbursements. Primary care offices saw even larger fee schedule differentials. 

Keep in mind that the location matters. For example, hospital comparison rates from the Medicaid and CHIP Payment and Access Commission (MACPAC) found that there were higher Medicaid than Medicare rates in 25 states, though lower in 22. 

How To Stay Up to Date on the Medicaid Physician Fee Schedule

You can stay up to date on Medicaid fee schedules by viewing information authorized herein by your state’s CMS website. We recommend reviewing information annually with your team. 

Gathering payment information, submitting claims, and handling insurance reimbursements is complex. Consider a payment collection platform that can make the entire process easier. 

At Weave, we offer comprehensive payment collection software with financing options, payment reminders, and more that can streamline how your office runs. We aim to help your practice reach scalable success. Call Weave today at 833-572-2139 to learn more about our platform or schedule a demo to see how our software can work for you.