Reimbursement Methods

Physician Reimbursement Methodology

Oklahoma has adopted the Medicare Resource Based Relative Value Scale (RBRVS) methodology as a benchmark for establishing fee-for-service payments to physicians and other limited licensed practitioners who bill the same as physicians.

Components of the Fee Schedule Payment Amounts

To calculate the payment for every physician service, the components of the fee schedule (physician work, Practice Expense (PE), and malpractice RVUs) are adjusted by a geographic practice cost index (GPCI). The GPCIs reflect the relative costs of physician work, PEs, and malpractice insurance in an area compared to the national average costs for each component. Payments are converted to dollar amounts through the application of a Conversion Factor (CF).

Oklahoma uses the geographically adjusted relative value units (RVU) and two (2) conversion factors (CF) to determine the payment rates for all available CPT and HCPCS codes, with the exception of anesthesia.

Relative value units

Medicare publishes updates to the RVUs annually prior to the start of the calendar year, to ensure that the payment system reflects changes in medical practice and the relative value of services. It is the intent of the Oklahoma SoonerCare program to automatically adjust the RVUs consistent with the Medicare updates, effective July 1 of each year. As of 7/1/2015, we are using the 2015 Medicare RVUs for payment. We are also refining payment for those services ordinarily performed in a facility setting (which receives separate payment from SoonerCare) to reflect the appropriate payment.

Conversion Factors

Although Medicare uses a single conversion factor, Oklahoma currently uses two. The CFs are as follows:

 

Provider Type 

Conversion Factors 

Non-State employed physicians and other practitioners 

$31.9111

State employed physicians 

$50.0566

Anesthesia

Anesthesia reimbursement methodology has been changed. Please see the linked documents below for an explanation of the changes.