Medicare in Oral and Maxillofacial Surgery Part 2: Academic Surgeons and Cancer Surgeons are Reimbursed Less

Publication date: Available online 26 November 2018

Source: Journal of Oral and Maxillofacial Surgery

Author(s): Yisi D. Ji, Zachary S. Peacock, James R. Hupp

Abstract

Purpose

To evaluate predictors of reimbursement of oral and maxillofacial surgery services in the Medicare population.

Methods

This is a cross-sectional study of Medicare Physician and Other Supplier Aggregate Data from 2015. Those classified as 'maxillofacial surgery' were included if they were confirmed to be an oral and maxillofacial surgeon (OMS) by National Provider Identifier (NPI) data. The primary outcome variable of this study was the proportion reimbursed (actual payment amount divided by charge amount divided). Predictor variables included type of practice (private vs. academic), scope (cancer vs. non-cancer), number of Medicare beneficiaries seen, number of unique CPT codes billed, and total amount charged. Descriptive statistics and regression analyses were calculated with a p-value of <0.05 considered significant.

Results

The initial search revealed 952 providers categorized as 'maxillofacial surgery,' with 894 confirmed to be an OMS (144 academic and 750 private practice). Of 894 OMSs, 39 were cancer surgeons and 855 non-cancer surgeons. Academic OMSs saw more complex patients compared to those in private practice (p<0.0001). Academic surgeons (n=144) charged an average of $116,876.92 to Medicare, with a mean payment amount of $22,219.62. Private practice surgeons (n=750) submitted an average charge of $27,812.56, with average reimbursement of $9,472.76.

Multiple linear regression revealed academia, cancer surgeons, number of unique CPT codes, higher HCC scores, and total submitted charge amount were negative predictors of proportion reimbursement.

Conclusion

Roughly 10% of OMSs participate and bill for Medicare. Factors associated with lower reimbursement proportion include being in academia, treatment of head and neck cancer, billing more unique CPT codes, seeing sicker patients, and larger total submitted charges. As third-party private insurers often follow fee schedules and rates set by the Centers for Medicare and Medicaid Services, this observed effect should also be evaluated in claims data of other insurers.

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