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Understanding Medicare Reimbursement Rates


Want to gain a better understanding of Medicare reimbursement rates? You might have better luck trying to win the lottery.

Given that there is a complex system of different hospitals and physicians to deal with, it’s easy to see why it can be so confusing.

“Medicare reimbursement” is the term used for the payments that hospitals or doctors are given in return for the care they administer to a Medicare beneficiary. The Medicare Reimbursement Rates are set by Medicare, and these rates are usually lower than the amount that is billed, or the amount that the healthcare provider would quote a private insurance company.

What is a Medicare Participating Provider?

A participating provider is any facility or physician who agrees to accept the rates that are set by Medicare. This means they accept the Medicare reimbursements for all services that are covered under Medicare, and anyone who is covered by Medicare can apply for them. The facility or physician bills Medicare directly for the covered services.

One recent analysis of the healthcare market (Kaiser Family Foundation) found that 93% of non-pediatric PCPs were classed as participating providers, though, it’s important to note that only 72% of them were currently accepting new patients covered by Medicare. For this reason, if a patient has a doctor they’re happy with, it’s worth trying to stay on their books.

What About Non-Participating Providers

Matters are further complicated when dealing with non-participating providers. There are a number of healthcare providers who are non-participating providers, and this means they do not accept the current Medicare reimbursement rates. If a patient seeks treatment from a facility or physician who is a non-participating provider, that patient may be asked to pay the bill up front,  then turn to Medicare for reimbursement of the amount normally to be paid. The provider will be paid 95% of the amount that is listed on the fee schedule. Then they are allowed to bill no more than 15 percent of the reimbursement amount. Some states set the limit even lower, at around five percent.

Opt-out providers

Lastly, there are some doctors who will not accept Medicare patients at all. It is estimated that roughly one percent of physicians opt out of Medicare completely. It is common for psychiatrists to do this, but some doctors are doing so as well. A physician who has opted out will not accept Medicare payments and will bill the patient directly. There is no limit to the bill that the provider can charge because they are essentially opting as a private business and the matter of billing is between their patients and themselves.

If you have additional questions about Medical Reimbursement Rates, feel free to contact Payer Compass for answers.

Sources: https://www.medicareresources.org/faqs/how-does-medicare-reimbursement-work/












Recapitalization for Our Company and What it Means

Payer Compass is known as a leading provider of healthcare reimbursement technology and and cost containment solutions. Recently, our company received an investment from Spectrum Equity and Health Enterprise Partners through recapitalization.

This investment allows us to continue our rapid growth, while making substantial progress in extending our services to brokers, health plans, third-party administrators, and self-insured employers.

What drove us to recapitalize?

We took this route for several reasons. First, we felt the movement of the competitive landscape and wanted to secure our place as a continued leader.   We’re also set to enhance infrastructure, expand product offerings, and grow our footprint in current and new markets. Additionally, we’ve been in business nearly six years, it’s about time we grow up, at least a little, and build our leadership team, and this will allow us to do so.

When we first considered recapitalization, we had to stop and consider both the mid- and long-term. Recapitalization is beneficial for expansion, something we’ve wanted to do. As funding comes into the picture, it accelerates the company’s progress as a whole. Essentially, Payer Compass is using this opportunity to grow and further bridge the gap between payers and providers, in order to ultimately help more people in need of affordable, quality healthcare. These opportunities wouldn’t be possible without this new partnership.

We want to build a strong company

Our new partners are successful in helping companies like ours integrate the pieces needed to maintain a substantial business, increase value, and construct a solid infrastructure, with the right resources and market strategy.  

We want to fulfill our potential

Though Payer Compass is still in somewhat of a nascent stage, we’ve made a huge, positive impact in the healthcare industry. We are proud to have grown the company to serve over 125 customers, representing nearly 1,000 employer groups, and over 2 million covered people.  We have also grown as an organization from two to 70 team members in under six years. But we don’t want to stop there or simply maintain, we want the ability to scale the business and break barriers that were preventing us from entering specific markets and gaining more opportunities. Our partnership with Spectrum and HEP allows us to continue to invest both in our team and in our assets – new technologies, new companies.

Why did we choose these partners? What do they do?

We took our time and vetted candidates carefully, looking to partner with firms who feel as passionate about healthcare affordability as we do, share our vision for growth, and share the same ideals about corporate culture. In the end, it came down to a feeling – choosing Spectrum Equity and Health Enterprise Partners (HEP) just felt right. Spectrum is a growth equity that provides capital and strategic support. This firm builds great value for market-leading software, information services, and internet companies. HEP invests in private, mid-market companies in healthcare services and health care information technology. HEP strives to improve quality in patient experience, increase accessibility and reduce overall costs of healthcare. Both firms possess extensive experience in scaling leading healthcare technology companies.

In our case, Payer Compass possesses the services and noticeable scale in the cost containment landscape that interests Spectrum. With pricing solutions such as our core platform, VISIUM, which focuses on the complexities of Medicare, Medicaid and Commercial healthcare claims, we  can address the rising costs of healthcare faced by self-insured employer groups and health plans, as well as the fundamental need for greater healthcare transparency. With the support we are receiving from Spectrum and Health Enterprise Partners, we will be able to further impact cost containment innovation.

Recapitalization will not cause our company culture to change

We’ve tried to cultivate a productive, hospitable culture that keeps our team members engaged. And while our recapitalization efforts mean a seismic shift in our business, we didn’t want to disrupt the culture. Our team is like a family, and we respect every individual’s skills, intelligence and uniqueness. Which is why we’re making every effort to maintain the same work environment we’ve always enjoyed.

While still maintaining operational and cultural control of our business, our solutions will continue to be implemented across key markets, as indicated by the growth of government-sponsored healthcare and reference based pricing.

Overall, these partnerships have bolstered the presence of  Payer Compass and are taking us in the right direction, with new strategies and capital for growth.

Finally, we’re excited to welcome Jeff Haywood, Steve LeSieur, and Michael Radonich from Spectrum Equity, along with  David Tamburri from HEP, to the Payer Compass family’s Board of Directors.

If you would like more information about this healthcare initiative, please contact Ginger Barrientez, Director of Marketing at 469.215.2654 or email at gbarrientez@payercompass.com.

payer compass-spectrum-recapitalization
Spectrum Equity

Best Practices for a Productive Organizational Culture in Healthcare

In a competitive and aggressive industry like healthcare, a productive organizational culture can give you the edge you need over the competition. Creating a pleasant environment where people can (and want to) do their best work is key to achieving a shared vision for the company, where everybody’s on the same page, and shooting for the same goal. Here at Payer Compass, we follow these best practices and we’ve included a few quotes so you can hear from our own team how well these recommendations work.

Here are some ways to improve your organizational culture:

Define your culture

Discuss your company beliefs, values and norms. Culture is more than just, “the way we do things around here.” It helps create the environment your team will work in and organically form a shared focus and vision. Don’t just plaster inspirational words around a board, do something fun and enjoyable for your team members to further engage in understanding why and how the company works the way they do.

“It’s fun. It’s hard work but we enjoy each other’s company and we enjoy working hard together, making a difference in the industry.” -Kellie Jackson, Vice President, Sales & Client Engagement

Hire to fit

Hiring people that fit your culture is key to maintaining it. A good way to do that is to communicate those company beliefs and values we talked about earlier during your interview process. You can’t hire someone with a different attitude towards your culture and expect the tone of the environment to stay the same. For example, your company has an office culture that is relaxed and casual, where everyone supports one another. However, you hired an employee who turns out to be loud, aggressive, and only cares about themselves. This would result in an uncomfortable workplace for everyone, and offset the overall balance that you tried so hard to maintain in your office.

“I like the environment and culture that we have here. I’ve come from a lot of different companies and this one just seems to suit everything that I’m looking for: a work life balance and just having a family. Because the majority of our week we spend it at work, right? This is my second family and this is my second home, I love what we do and I’m all about it.” -Stephanie Nguyen, Senior Account Representative, Client Services

Goal transparency

Set up clear goals for your company to strive to reach. Putting an emphasis on the bigger picture lets your team know there is a vision that everyone is expected to adapt.

“The people here, they care. It’s like a family. Folks are gonna be working hard together to get to the same place, and in a lot of other instances I’ve had to fight to get a solution. I’ve had to struggle to get from point a to point b, when we all know where point b is where we need to go. But here, and while we might not agree all the time, everybody understands the goal, everybody understands where we’re headed, and I think everybody enjoys to be a part of something that’s, at the end of the day, it’s groundbreaking.” -Jeff Winslow, Director of Client Services

Develop a plan for measurable improvement

Developing a key metrics system for improving employee performance is vital to living up to the vision that your goal setting is focused on. Keeping track and seeing progress towards personal and organizational goals is an efficient and effective way for your team to achieve them. This also allows each of your team members to give focus to those key areas that may require improvement.

Create unity

Creating a unified team is something that every company should practice in the workplace. Get to know your team members and encourage them to play to their strengths in order to strategically create a synergized effort when working towards company goals. Making connection between others is a priority in order to achieve a great overall performance and operational success when overcoming obstacles in the industry.

“Working with this [Payer Compass] family, like this team, one of my favorite mottos is, “Teamwork makes the dream work” and it sounds so silly, but I literally love that we’re all a family here and we collaborate and work together and we really make a difference and we do it successfully as a team to make the dream work. That’s what I love about Payer Compass.” -Stephanie Nguyen, Senior Account Representative, Client Services

Give them freedom, fun, and appreciation

It’s time for companies to quit treating employees like robots or second-rate individuals and actually treat them like people. People do not like to be managed to the point that they feel dictated, they know what to do and it would be nice to give them some space to do their work stress-free. Let team members  be self directed, and step in only for group discussions about their progress on company goals. A great idea is to implement a “fun” day of the month in the office, where everyone can engage in fun, yet functional activities. Encourage your team to experiment with new ideas on how things can be done better and have them share their findings during your next group discussion. Lastly, vocalizing your appreciation for your team as a whole and individually will give each one of them a sense of belonging and purpose that will result in loyalty for your company.

“It’s a challenging job, it’s a rewarding job though and it’s great to work with people that you know and like and really care about that you have worked with for a long time.” -Timothy Martin, EVP and General Counsel


Here at Payer Compass, we’re a unified group who practice the principles of commitment, community, communication, and care into every aspect of our work. We are committed to helping others, and work hard for our community by means of communicating effectively with those who care.