Physician reimbursement for medical (non-psychiatric), surgical, and anesthesia services

Kaiser Permanente calculates allowable reimbursement at the lower of charges or the maximum amount allowable on the pertinent Kaiser Permanente Washington provider reimbursement schedule described below.

Paid amounts shall reflect the maximum allowable amount less any applicable coinsurance, copayments, and deductible amounts.

Medicare services

The Kaiser Permanente provider reimbursement schedule for services provided to Medicare members will generally reflect prevailing Medicare payment levels as they are revised in accordance with the Centers for Medicare and Medicaid Services'(CMS) fee schedule and payment methodology.

Commercial services

The Kaiser Permanente Washington provider reimbursement schedule for services provided to commercial members is generally based on the CMS Resource-Based Relative Value Scale (RBRVS) relative value units (RVUs), payment policies and methodology.

Final RVU values reflect adjustments for:
Geographic adjustments (GPCI), using values for King County and "Rest of Washington"
Non-Facility Practice and Facility Practice Expense RVU differential for site-of-service

The final RVU calculation is rounded to two decimal places.

Where CMS does not provide an RBRVS-based RVU, gap filler methodology is applied. When no gap-filler is available, Kaiser Permanente Washington will price the service at a percent of the billed charges until CMS assigns an RVU or the gap-filler methodology provides a value. Codes that are considered "by report" will be reviewed for medical necessity and priced accordingly if appropriate.

Kaiser Permanente Washington updates its professional provider reimbursement schedule periodically by adding new codes and deleting retired codes. In most instances, RVUs are assigned to new and revised codes in accordance with CMS geographically adjusted RBRVS schedule, other CMS schedules, and gap filler methodology.

Discrete facility charges for evaluation and management services provided to commercial managed-care members are not reimbursable, nor is the member liable for these charges. The Kaiser Permanente provider reimbursement schedule utilizes the prevailing Medicare Part B Drug Payment Allowance Pricing File, updated quarterly, for drugs furnished incident to physician services.

The Kaiser Permanente Washington provider reimbursement schedule utilizes the American Society of Anesthesiologists (ASA) base units and 5 time units per hour in calculating reimbursement for anesthesia services billed with base units and time. Time units are rounded to the first decimal place. For neuraxial labor anesthesia, 5 units are assigned to the first hour and 1 unit for each additional hour or partial hour. Relative value units for procedures and pain management services provided by anesthesiologists are derived from the RBRVS system described above.

Facility charges for evaluation and management services

Discrete facility charges for evaluation and management services provided to commercial managed-care members are not reimbursable. Such services, when provided to Medicare managed-care members, shall continue to follow Medicare payment rules.

1. Evaluation and management services are defined as Current Procedural Terminology codes 99201-99215, 99381-99395, 99401-99429, 99495-99496, 99078, G0463, payment for which is allowed only when billed on a CMS-1500.
2. Discrete facility charges associated with evaluation and management services are not reimbursable for commercial managed-care members, regardless of revenue code billed. Commercial managed-care members shall not be liable for these charges.
3. Professional services for evaluation and management services are reimbursed under the Kaiser Permanente Washington provider reimbursement schedule.

For more information about facility charges for evaluation and management services, see Kaiser Permanente payment policies.