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

Purpose: The purpose was to evaluate predictors of reimbursement of oral and maxillofacial surgery services in the Medicare population.
Materials and Methods: This was a cross-sectional study of Medicare Physician and Other Supplier Aggregate Data from 2015. Clinicians were included if they were confirmed to be oral and maxillofacial surgeons (OMSs) by National Provider Identifier data. The primary outcome variable of this study was the proportion reimbursed (actual payment amount divided by charge amount). Predictor variables included type of practice (private vs academic), scope (cancer vs non-cancer), number of Medicare beneficiaries seen, number of unique Current Procedural Terminology (CPT) codes billed, and total amount charged. Descriptive statistics and regression analyses were calculated, with P < .05 considered significant.
Results: The initial search revealed 952 providers categorized as performing maxillofacial surgery, with 894 confirmed to be OMSs (144 academic and 750 private practice). Of 894 OMSs, 39 were cancer surgeons and 855 were non-cancer surgeons. Academic OMSs saw more complex patients than OMSs in private practice (P < .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 showed that academia, cancer surgeons, number of unique CPT codes, higher Hierarchal Condition Category scores, and total submitted charge amount were negative predictors of the proportion of reimbursement.
Conclusions: Roughly 10% of OMSs participate in and bill for Medicare. Factors associated with a lower reimbursement proportion include being in academia, treating head and neck cancer, billing more unique CPT codes, seeing sicker patients, and having larger total submitted charges. As third-party private insurers often follow fee schedules and rates set by the Centers for Medicare & Medicaid Services, this observed effect also should be evaluated in claims data of other insurers.
(Copyright © 2018 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)