Posts Tagged overpayments


The Cohen Report: What is the National Average Charge for 10,500 HCPCS Codes?

Frank writes:

I have finally completed my analysis of the 2009/2010 P/SPS (Physician/Supplier Procedure Summary) Master File.  This file contains 100% of all claims submitted to Medicare during a given calendar year, along with a mid-year 5% update. For this analysis, I used around 2.5 billion claim lines that represent nearly every physician in every specialty in the US. For this run, I analyzed the charges submitted to the database and created a file that reports the national average charge for over 10,500 procedure codes.  Each procedure code (and modifier, when applicable), report the weighted average charge, the variation (standard deviation) and the sample error. The latter two will allow you to determine the value of the point estimate.

From the Report:

Level 1        Office/outpatient visit, est     38.11

Level 2        Office/outpatient visit, est     65.04

Level 3        Office/outpatient visit, est     92.54

Level 4        Office/outpatient visit, est     140.74

Level 5        Office/outpatient visit, est     198.77

Remember, even though the data come from the Medicare database, our studies show that nearly 95% of all providers submit their retail (or usual) charge so that this is an excellent source for a fee schedule analysis.

To get this file (at no charge),

go to and click on the Download tab. When you get to the download page, it will be the second link down.

Also, I am going to be the keynote speaker

(as well as conducting some break-out sessions) for the 2011 Physicians RAC Summit to be held in Orlando, FL the second week of January. I am going to be talking about two major issues; how to assess your risk for an audit and then how to determine whether the post-audit overpayment estimates are calculated properly. So far, in nearly every analysis I have conducted, the overpayment estimate was wrong and, not surprisingly, biased towards the RAC, not the provider. To get more information, go to my website at and click on the RAC Summit link.

Please let me know if you have any questions or if I can be of assistance in any way.

Frank Cohen, MPA, MBB

Posted in: Finance

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What Health Care Providers Need To Know About Medicare and the RAC

Carla Hannibal

By Carla Hannibal, CMM,CPM,CIMBS

Recovery Audit Contractors (RACs) will pursue corrections of Medicare claims by auditing for overpayments and underpayments under Part A or B of the title XVIII of the Social Security Act.  Health care providers will be affected as Medicare has recently contracted with RACs for 2009 and beyond.  RACs will audit every United States and Peurto Rico health care provider who files with Medicare.  The audit and recovery plan is expected to be in place by (more…)

Posted in: Headlines, Medicare & Reimbursement

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