Reimbursement

Reimbursement usually means receiving money in repayment for money you have already spent, or an expense you have already incurred. It is a term used in a wide variety of ways in business and personal life, but it has a different meaning in healthcare.

Healthcare providers are paid by insurance or government payers, such as Medicare through a system of reimbursement.

  • They provide medical services to a patient and then file for reimbursement for those services with the insurance company or government agency. It’s not the patient who is paying out of pocket and getting reimbursed, it is the doctor providing the service and awaiting reimbursement.
  • Whenever you have a medical procedure performed or health care service provided, it is coded in your medical record for tracking and billing. CPT codes and HCPCS codes are related systems of medical coding required for providers and insurers to send information electronically.
  • You can look up a procedure by code to see how much Medicare reimburses your doctor or hospital to perform it.
  • A private insurance company negotiates their own reimbursement schedules with providers and hospitals.

Even with health insurance, patients may have to pay a co-pay for a medical procedure, or may have to pay out of pocket for procedures not covered by insurance or Medicare.

When it comes specifically to HIFU and medical reimbursement, the following  information may be helpful.

Commercial Insurance (private insurance provider)

  1. At this time, there is not a CPT code for HIFU that is recognized by any commercial insurance plan.
  2. No commercial insurance plan has a policy that covers HIFU, in fact most plans have a policy that states it is not covered.
  3. HIFU Prostate Services is out-of-network for 100% of insurance carriers in the US, and will not be able to assist you in filing for reimbursement.

Medicare

  1. While there is an approved reimburse rate for HIFU for Medicare patients, as of January 1, 2019 The Centers for Medicare and Medicare Services (CMS) lowered that facility reimbursement rate so much that facilities can not actually afford to offer HIFU as a treatment options.
  2. The new reimbursement rate will not even cover the cost of the materials needed to perform the procedure.
  3. All Medicare credentialed facilities contracted with HIFU Prostate Services to treat HIFU patients have requested HPS physician stop preforming HIFU at their facilities until this issue is resolved.
  4. If you are a patient with Medicare you can still choose to have HIFU. However, it will be at a non-Medicare credentialed facility and you will be responsible for 100% of the cost of the procedure.

Want more information? or Want to help advocate for changes to the HIFU reimbursement rate? Contact Us at 1-877-884-HIFU (4438).