Estimating Medicare published rates given CPT code and locality
I am working on setting up psychotherapy with an out-of-network provider and am trying to estimate my out-of-pocket costs. I have verified that the services are covered under the plan, but I want to see if I'll end up going way over the rate my insurance will pay. I have the codes the provider typically bills and the specific locality and I am trying to use the CMS tool to compute an estimate of the "eligible expense" for the procedures. Eligible expenses is defined in my SPD as "determined based on 150% of the published rates allowed by the Centers for Medicare and Medicaid Services (CMS) for Medicare for the same or similar service within the geographic market."
I have tried for nearly an hour to get any estimate from my insurance company what the eligible expense might be around or guidance on how to obtain the "published rates", but they won't give me any information – I guess they don't want to say something incorrect…
I'm hoping someone can help me determine what that terminology means and offer guidance on how to track that value down. My best guess is it is one of the "non-facility price", "non-facility limiting charge" (both from the CMS tool output) or some factor applied to one of those.
submitted by /u/datboiforever
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