Why Medicare Matters Even if You Don’t Bill Medicare

Insurance payment affects your ability to sustain a practice and provide the care patients need. Medicare influences that payment landscape because many Medicaid programs and commercial insurers use its payment values or policies as a reference. Understanding how codes and payment decisions connect can help you work with payers and participate in advocacy—even if you never submit a Medicare claim.

Why the Medicare Physician Fee Schedule Matters

Each year, the Centers for Medicare & Medicaid Services (CMS) publishes the Medicare Physician Fee Schedule (MPFS). Despite its name, the MPFS establishes outpatient payment for services across many health professions—including audiology, speech-language pathology, physical and occupational therapy, medicine, advanced practice nursing, and mental health care. Its payment policies therefore have broad implications for health care practices and patient access, although the effects differ across professions and services.

In addition to introducing numerous policy changes each year, the MPFS addresses Medicare implementation of new and revised codes and other regulatory updates that affect Medicare providers and their practices.

For new and revised CPT codes, the annual MPFS is an important step toward implementation: it establishes how Medicare will value and pay for those services.

Who Makes Coding and Payment Decisions

The American Medical Association’s (AMA) CPT Editorial Panel approves CPT codes and descriptions. Its Relative Value Scale Update Committee (RUC) recommends values that reflect clinician work and the resources needed to provide services. CMS decides Medicare’s values and payment policies. ASHA contributes clinical expertise, member survey data, and recommendations throughout these processes. Learn more in Understanding the CPT® Process: How Codes Are Created and Valued.

Medicare calculates payment using the relative values assigned to a service and a dollar multiplier called the conversion factor, with adjustments for geographical location and other policies. Changes to a service’s values and changes to this broader payment formula can both affect the final reimbursement.

Congress sets key requirements that shape Medicare payment, including government spending controls that directly impact Medicare payment updates. CMS implements those requirements and makes regulatory decisions. Improving payment therefore requires advocacy with both Congress and CMS, alongside work with other payers.

What Medicare Means for Other Payers

Medicare’s decisions can influence other payers, but they do not establish one payment rate or set of billing rules for everyone. Medicaid programs and commercial insurers set their own requirements, subject to applicable law and contracts. A Medicare payment change does not automatically produce an identical change from another payer. Although Medicare does not establish payment rates for Medicaid or other payers, its policies and reimbursement methodologies often influence how other payers structure their coverage, coding, and payment policies.

Medicare also establishes the National Correct Coding Initiative (NCCI) edits. Other payers may adopt the Medicare coding edits that determine which services may be billed together and when additional information is required. These edits may differ across Medicare, Medicaid, and commercial insurance and may change separately from payment rates.

What You Can Do

Medicare and the MPFS are parts of a larger implementation process. Clinicians still need to review each payer’s coverage, payment rates, authorization requirements, and billing instructions when codes or policies change. Confirm that your documentation and billing systems support those requirements. Share specific examples of payment or coverage barriers with ASHA, including the payer, state, services involved, and effect on patient care.

For coding or payer information, visit ASHA’s billing and reimbursement resources.

To support payment reform, visit ASHA’s Take Action Center for current opportunities to contact Congress.