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THE 5ECPETARY OF HEALTH AND HUMAN SEPVtCES 



3 1994 



The Honorable Albert Gore, Jr. 
President of the Senate 
Washington, D.C. 20510 

Dear Mr. President: 




I am pleased to submit this letter and the enclosed tables as our 
report to you under section 1848(g)(6) of the Social Security Act 
(the Act), as added by the Omnibus Budget Reconciliation Act of 
1989. That section requires me to report annually on 
participation, assignment, and extra billing in the Medicare 
program. This is the third annual report submitted pursuant to 
that statutory provision. 

Pursuant to our monitoring responsibility under the Act, we 
reviewed data to determine whether, in 1993, financial liability 
increased for Medicare beneficiaries when they used services paid 
for under the Medicare physician fee schedule. We are pleased to 
report that in 1993 Medicare beneficiaries generally experienced 
a substantial reduction in their overall financial liability. 

Since 1984, the Medicare program has had a participation program- 
under which physicians and suppliers are invited, on an annual 
basis, to sign a Medicare participation agreement. Those 
agreements require a participant to accept assignment--i . e . , to 
accept the Medicare allowance amount as payment in full--for 
services rendered to all Medicare beneficiaries. One major 
advantage of participation is that participants have Medicare 
allowance amounts that are 5 percent higher than the allowance 
amounts for nonparticipants . Physicians and suppliers who choose 
not to participate are free to accept or not to accept assignment 
on a case-by-case basis. 

From 1992 to 1993, the percent of Medicare allowed charges billed 
on an assignment-related basis- -by both participants and 
nonparticipants--increased from 86.5 percent to 91.1 percent. 
This meant that the percent of unassigned charges decreased from 
13.5 to 8.9, a decrease of 34.1 percent. (See table 1.) This 
national pattern of increasing assignment rates is mirrored in 
virtually every State (table 1), in every specialty (table 2), 
and in every type of service (table 3). Of course, in States 
where assignment rates were already close to 100 percent-- 
sometimes because of State mandatory assignment provisions--the 
assignment rate increases were minuscule. See, for example, in 



Page 2 - The Honorable Albert Gore, Jr. 



table 1, Massachusetts, Nevada, Pennsylvania, Rhode Island 
Puerto Rico, and the Virgin Islands. 

In addition to there having been an increase in the overall 
assignment rate attributable to both participating and 
nonparticipating physicians, in 1993, we also saw a substantial 
increase (10.7 percent) in the proportion of allowed charges 
billed by participants, i.e., by the providers who must always 
bill on an assignment-related basis. In 1993, participating 
physicians and suppliers billed 83 percent of total allowed 
charges--up from 75 percent in 1992. This meant that, in 1993, 
only 17 percent of Medicare allowed charges were billed by 
nonparticipants . In every State, in almost every specialty, and 
in every type of service category, we found this same trend, 
i.e., an increase in the proportion of allowed charges billed by 
participating providers and parallel decreases in the proportion 
of allowed charges (both assigned and unassigned) billed by 
nonparticipants. See tables 4, 5, and 6. 

This trend of participants having an increasing share of the 
Medicare market is consistent with the fact that the numbers of 
participants continues to rise. During 1993, almost 60 percent 
of physicians and practitioners were signed-on as Medicare 
participants. That number represented about a 14 percent 
increase over the 1992 participation rate. After the most recent 
enrollment, for the participation period which began on 
January 1, 1994, 64.8 percent of physicians and other 
practitioners were participants. This 1994 increase in 
participation occurred in every specialty and in almost every 
State. See tables 7 and 8. 

Another measure of the financial exposure being experienced by 
Medicare beneficiaries is the extra billing rate for unassigned 
allowed charges billed by nonparticipants. The extra billing 
rate is the ratio of extra billing to total unassigned allowed 
charges, with extra billing defined as the difference between the 
submitted charge and the allowed charge on unassigned claims. 
While it is important to recognize that the above figures reflect 
that more and more Medicare services are being billed on an 
assignment-related basis and by participants, it is critical for 
us to examine the amount of exposure there is for beneficiaries 
when assignment is not being accepted and charges are being 
imposed above the allowed charge level. That is what a review of 
extra billing rates will tell us. 

From 1992 to 1993, extra billing rates decreased by 26.8 percent. 
The rate dropped from 22.8 percent in 1992 to 16.7 percent in 
1993. We saw this reduction in every State, in all physician 
specialties except one, and in all type of service categories 
except one. We found that, in 1993, for the anesthesia type of 



Page 3 - The Honorable Albert Gore, Jr. 



service category and for anesthesiologists as a specialty, extra 
billing rates on unassigned claims increased. See tables'9, 
10, and 11. In our judgment, the 1993 extra billing rate of 
16.7 percent reflects substantial compliance with the Medicare 
provision known as the "limiting charge." The 1993 limiting 
charge capped the charges of nonparticipating physicians at 
115 percent of the Medicare fee schedule amount. (Effective 
January 1, 1994, the limiting charge applies to all services 
furnished by suppliers and practitioners covered under the 
physician fee schedule.) Our administrative data do not tell us 
how much of any difference between submitted and allowed charges 
are actually paid. Also, some charges that were actually paid 
may have been refunded by physicians subsequent to Medicare 
carrier monitoring and notices. 

We are concerned that, while the data indicate good compliance 
with the limiting charge provision, there are several specialties 
(e.g., anesthesiology) and geographic areas (e.g.. New York, 
Hawaii, and Alaska) which indicate that increased efforts are 
needed to assure that beneficiaries receive the full financial 
protections intended by the law. While all unassigned claims are 
currently monitored for compliance with the limiting charge 
provision, we will initiate a special analysis to identify why 
problems still remain in these specialties and geographic areas 
and will take whatever further actions are required to ensure 
limiting charge compliance. 

We have also enclosed table 12, which examines national summary 
data by age, race and sex. You will observe, in that table, 
that, between 1992 and 1993, the Medicare assignment rate 
increased for males and females, for all race categories and for 
all age categories. Males and females continue to have roughly 
the same assignment rate, while among the race categories. 
Medicare beneficiaries who are black have the highest assignment 
rate at 97.8 percent. Data in table 12 also indicate that the 
extra billing rate went down for all categories of beneficiaries 
in 1993. 



We believe that these findings are very positive and are pleased 
to report them to Congress. I am also sending a copy of this 
report to the Speaker of the House of Representatives. 




Enclosures 



THE SECRETARY Of HEALTH AND HUMAN bE^5 vi' £S 



AUG 3 1994 



The Honorable Thomas S. Foley 

Speaker of the House of Representatives 

Washington, D.C. 20515 

Dear Mr. Speaker: 

I am pleased to submit this letter and the enclosed tables as our 
report to you under section 1848(g)(6) of the Social Security Act 
(the Act), as added by the Omnibus Budget Reconciliation Act of 
1989. That section requires me to report annually on 
participation, assignment, and extra billing in the Medicare 
program. This is the third annual report submitted pursuant to 
that statutory provision. 

Pursuant to our monitoring responsibility under the Act, we 
reviewed data to determine whether, in 1993, financial liability 
increased for Medicare beneficiaries when they used services paid 
for under the Medicare physician fee schedule. We are pleased to 
report that in 1993 Medicare beneficiaries generally experienced 
a substantial reduction in their overall financial liability. 

Since 1984, the Medicare program has had a participation program 
under which physicians and suppliers are invited, on an annual 
basis, to sign a Medicare participation agreement. Those 
agreements require a participant to accept assignment--i . e . , to 
accept the Medicare allowance amount as payment in full--for 
• services rendered to all Medicare beneficiaries. One major 
advantage of participation is that participants have Medicare 
allowance amounts that are 5 percent higher than the allowance 
amounts for nonparticipants . Physicians and suppliers who choose 
not to participate are free to accept or not to accept assignment 
on a case-by-case basis. 

From 1992 to 1993, the percent of Medicare allowed charges billed 
on an assignment-related basis--by both participants and 
nonparticipants--increased from 86.5 percent to 91.1 percent. 
This meant that the percent of unassigned charges decreased from 
13.5 to 8.9, a decrease of 34.1 percent. (See table 1.) This 
national pattern of increasing assignment rates is mirrored in 
virtually every State (table 1), in every specialty (table 2), 
and in every type of service (table 3). Of course, in States 
where assignment rates were already close to 100 percent-- 
sometimes because of State mandatory assignment provisions--the 
assignment rate increases were minuscule. See, for example, in 



Page 2 -.The Honorable Thomas S. Foley 



table 1, Massachusetts, Nevada, Pennsylvania, Rhode Island, 
Puerto Rico, and the Virgin Islands. 

In addition to there having been an increase in the overall 
assignment rate attributable to both participating and 
nonparticipating physicians, in 1993, we also saw a substantial 
increase (10.7 percent) in the proportion of allowed charges 
billed by participants, i.e., by the providers who must always 
bill on an assignment-related basis. In 1993, participating 
physicians and suppliers billed 83 percent of total allowed 
charges--up from 75 percent in 1992. This meant that, in 1993, 
only 17 percent of Medicare allowed charges were billed by 
nonparticipants . In every State, in almost every specialty, and 
in every type of service category, we found this same trend, 
i.e., an increase in the proportion of allowed charges billed by 
participating providers and parallel decreases in the proportion 
of allowed charges (both assigned and unassigned) billed by 
nonparticipants. See tables 4, 5, and 6. 

This trend of participants having an increasing share of the 
Medicare market is consistent with the fact that the numbers of 
participants continues to rise. During 1993, almost 60 percent 
of physicians and practitioners were signed-on as Medicare 
participants. That number represented about a 14 percent 
increase over the 1992 participation rate. After the most recent 
enrollment, for the participation period which began on 
January 1, 1994, 64.8 percent of physicians and other 
practitioners were participants. This 1994 increase in 
participation occurred in every specialty and in almost every 
State. See tables 7 and 8. 

Another measure of the financial exposure being experienced by 
Medicare beneficiaries is the extra billing rate for unassigned 
allowed charges billed by nonparticipants. The extra billing 
rate is the ratio of extra billing to total unassigned allowed 
charges, with extra billing defined as the difference between the 
submitted charge and the allowed charge on unassigned claims. 
While it is important to recognize that the above figures reflect 
that more and more Medicare services are being billed on an 
assignment-related basis and by participants, it is critical for 
us to examine the amount of exposure there is for beneficiaries 
when assignment is not being accepted and charges are being 
imposed above the allowed charge level. That is what a review of 
extra billing rates will tell us. 

From 1992 to 1993, extra billing rates decreased by 26.8 percent. 
The rate dropped from 22.8 percent in 1992 to 16.7 percent in 
1993. We saw this reduction in every State, in all physician 
specialties except one, and in all type of service categories 
except one. We found that, in 1993, for the anesthesia type of 



Page 3 --The Honorable Thomas S. Foley 



service category and for anesthesiologists as a specialty, extra 
billing rates on unassigned claims increased. See tables 9, 
10, and 11. In our judgment, the 1993 extra billing rate of 
16.7 percent reflects substantial compliance with the Medicare 
provision known as the "limiting charge." The 1993 limiting 
charge capped the charges of nonparticipating physicians at 
115 percent of the Medicare fee schedule amount. (Effective 
January 1, 1994, the limiting charge applies to all services 
furnished by suppliers and practitioners covered under the 
physician fee schedule.) Our administrative data do not tell us 
how much of any difference between submitted and allowed charges 
are actually paid. Also, some charges that were actually paid 
may have been refunded by physicians subsequent to Medicare 
carrier monitoring and notices. 

We are concerned that, while the data indicate good compliance 
with the limiting charge provision, there are several specialties 
(e.g., anesthesiology) and geographic areas (e.g.. New York, 
Hawaii, and Alaska) which indicate that increased efforts are 
needed to assure that beneficiaries receive the full financial 
protections intended by the law. While all unassigned claims are 
currently monitored for compliance with the limiting charge 
provision, we will initiate a special analysis to identify why 
problems still remain in these specialties and geographic areas 
and will take whatever further actions are required to ensure 
limiting charge compliance. 

We have also enclosed table 12, which examines national summary 
data by age, race and sex. You will observe, in that table, 
that, between 1992 and 1993, the Medicare assignment rate 
increased for males and females, for all race categories and for 
all age categories. Males and females continue to have roughly 
the same assignment rate, while among the race categories. 
Medicare beneficiaries who are black have the highest assignment 
rate at 97.8 percent. Data in table 12 also indicate that the 
extra billing rate went down for all categories of beneficiaries 
in 1993. 

We believe that these findings are very positive and are pleased 
to report them to Congress. I am also sending a copy of this 
report to the President of the Senate. 




Enclosures 



TABLE 1 

Assigned and Unassigned Allowed Charges as Percent of Total Allowed Charges, By Stal^ 



STATE 


Assigned ' 




t 

i Unassigned 


Percent of Total 
Allowed Charges 


Percent 
Change 

1992-1993 


Percent of Total 
Allowed Charges 


r erceni 
onange 


1992 


1993 


1992 


1993 


1992-1993 


Alabama 


95.2 % 


97.2 % 


2.1 % 


4.9 % 


2.8 % 


-42.9 % 


Alaska 


88.9 


91.3 


2.7 


11.1 


8.7 


-21.6 


Arizona 


81.2 


86.9 


7.0 


18.8 


13.2 


-29.8 


Arkansas 


93.4 


95.8 


2.6 


6.6 


4.3 


-34.8 


CaJrfornia 


87.4 


92.1 


5.4 


12.6 


7.9 


-37.3 


Colorado 


75.3 


83.9 


11.4 


24.7 


16.0 


-35.2 


Connecticut 


89.2 


92.5 


3.7 


10.8 


7.5 


-30.6 


Delaware 


92.9 


94.6 


1.8 


7.2 


5.4 


-25.0 


District of Columbia 


88.6 


90.8 


2.5 


11.4 


9.1 


-20.2 


Florida 


89.0 


93.8 


5.4 


11.0 


6.2 


•43.6 


Georgia 


87.7 


92.0 


4.9 


12.3 


8.0 


-35.0 


Hawaii 


91.4 


94.5 


3.4 


8.6 


5.5 


-36.0 


Idaho 


37.3 


50.2 


34.6 


62.7 


49.8 


-20.6 


Illinois 


79.0 


87.2 


10.4 


21 .0 


12.8 


-39.0 


Indiana 


84.5 


90.3 


6.9 


15.5 


9.7 


-37.4 


Iowa 


72.6 


81.0 


11.6 


27.4 


19.0 


-30.7 


Kansas 


92.7 


94.8 


2.3 


7.3 


5.3 


-27.4 


Kentucky 


89.7 


94.2 


5.0 


10.3 


5.8 


-43.7 


Louisiana 


91.7 


94.3 


2.8 


8.3 


5.7 


-31.3 


Maine 


95.4 


96.7 


1.4 


4.6 


3.3 


-28.3 


Maryland 


93.2 


94.7 


1.6 


6.8 


5.3 


-22.1 


Massachusetts 


99.4 


99.5 


0.1 


0.6 


0.5 


-16.7 


Michigan 


95.0 


97.3 


2.4 


5.0 


2.8 


-44.0 


Minnesota 


46.4 


55.7 


20.0 


53.6 


44.3 


-17.4 


Mississippi 


90.9 


93.9 


3.3 


9.1 


6.0 


-34.1 


Missouri 


81 .3 


89.2 


9.7 


18.7 


10.8 


■42.2 


Montana 


58.1 


69.9 


20.3 


41.9 


30.1 


-28.2 


Nebraska 


70.5 


79.6 


12.9 


29.5 


20.4 


-30.8 


Nevada 


98.2 


98.5 


0.3 


1.8 


1.5 


-16.7 


New Hampshire 


85.4 


91.4 


7.0 


14.7 


8.6 


-41.5 


New Jersey 


75.7 


81.8 


8.1 


24.3 


18.2 


-25.1 


New Mexico 


83.9 


89.6 


6.8 


16.1 


10.4 


-35.4 


New York 


84.3 


87.4 


3.7 


15.7 


12.6 


-19.7 


North Carolina 


87.0 


90.4 


3.9 


13.0 


9.6 


-26.2 


North Dakota 


63.2 


64.2 


1.6 


36.8 


35.8 


-2.7 


Ohio 


90.6 


98.7 


8.9 


9.4 


1.3 


-86.2 


Oklahoma 


73.5 


82.6 


12.4 


26.5 


17.4 


-34.3 


Oregon 


65.4 


77.8 


19.0 


34.6 


22.2 


-35.8 


Pennsylvania 


98.8 


99.1 


0.3 


1.2 


0.9 


-25.0 


Rhode Island 






0.2 


0.9 


0.4 


-20.0 


South Carolina 


88.1 


91 .8 


4.2 


11.9 • 


8.2 


-31.1 


South Dakota 




H I .O 


17.7 


(54.9 


0O.7 


•9.6 


Tennessee 


92.4 


94.9 


2.7 


7.6 


5.1 


-32.9 


Texas 


84.2 


89.0 


5.7 


15.8 


11.0 


-30.4 


Utah 


85.4 


91.6 


7.3 


14.7 


8.3 


-43.5 


Vormont 


96.9 


97.9 


1 .0 


3.1 


2.1 


-32.3 


Virginia 


89.5 


93.9 


4.9 


10.5 


6.1 


-41.9 


wosningion 


68.3 


78.3 


14.6 


31.7 


21.8 


-31 .2 


West Virginia 


96.2 


97.7 


1.6 


3.8 


2.3« 


-39.5 


Wisconsin 


73.8 


84.3 


14.2 


26.2 


15.6 


-40.5 


Wyoming 


54.0 


65.7 


21.7 


46.0 


34.4 


•25.2 


Puerto Rico/Virgin Is. 


98.8 


99.0 


0.2 


1.2 


1.0 


-16.7 


Total' 


86.5 


91.1 


5.3 


13.5 


8.9 


-34.1 



' Based on allowed charges of participating and nonparticipating pfrysicians/practitioners. 
' Includes allowed charge data for physicians' services for Railroad Retirement Board claims. 



Based on summary data from the 1 993 National Cltums History for physicians' services incurred and processed from 
January through December 1993. 

SOURCE: Bureau of Data Management and Strategy 



TABLE 2 

Assigned and Unassigned Allowed Charges as Percent of Total Allowed Charges, By Specialty 





Assigned ' 


Unassigned 


Specialty 


Percent of Total 


Percent 


Percent of Total 


Percent 




Allowed Charges 


Change 


Allowed Charges 


Change 




1992 




1993 


1992-1993 


1992 


1 J7s70 


1992-1993 


Ail Spociaities ^ 


86.5 % 


91.1 % 




5.3 % 


13.5 % 


o.y TO 


-34.1 % 


Physicians (MOs and OOs) 


86.5 


91 .2 


5.4 


13.6 


8.8 


-35.3 


Family Practice 


79.7 


85.5 


7 a 


20.3 




-28.6 


General Practice 


86.2 


90.4 


4.9 


13,8 




-30.4 


Cardiology 


90.0 


94.0 




10.0 


6.0 


-40.0 


Dermatology 


83.8 


87.9 




1B9 

1 D,£ 


10 1 


-25.3 


Internal Medicine 


81 .3 


86.7 


6.6 


18.7 


IT? 


-28.9 


Gastroenterology 


89.8 


93.2 


3.8 


10.2 


V.O 


-33.3 


Nephrology 


95.2 


96.6 


1 s 


4.8 




-29.2 


Neurology 


87.3 


91.7 


5.0 


12.7 




-34.6 


Obstetrics-Qyn ecology 


81 .6 


86.6 


6.1 


18.4 


13.4 


-Z7.Z 


Psychiatry 


90.6 


92.1 


1 .7 


9.4 


7.9 


-lO.O 


Pulmonaiy 


90.2 


94.3 


4.5 


9.8 


5.7 


_A1 B 

-^1 .0 


Urology 


80.7 


88.1 


9.2 


19.3 


11.9 




Anesthesiology 


79.9 


39.5 


12.0 


20.2 


10.5 


-48.0 


Patfiology 


91.1 


94.5 


3.7 


8.9 


5.5 




Radiology ^ 


90.2 


94.6 


4.9 


9.8 


5.4 


-44.9 


General Surgery 


89.3 


94.0 


5.3 


10,8 


6.0 


AA A 
"^^.^ 


Neurosurgery 


84.6 


91.4 


8.0 


15.3 


8.6 


-JA A 


Ophthalmology 


89.6 


92.8 


3.6 


10.4 


7,2 


a 

"OW.O 


Orthopedic Surgery 


84.1 


91.6 


8.9 


15.9 


8.4 




Otolaryngology 


82.1 


87.7 


6.8 


18.0 


12.3 


-31.7 


Plastic Surgery 


89.0 


93.4 


4.9 


11.0 


6.6 


-40.0 


Thoracic Surgery 


89.8 


93.7 


4.3 


10.1 


6.3 


-37.6 


Clinic or Other Group Practice 


88.7 


94.0 


6.0 


11,2 


6.0 


-46.4 


All Other Physicians 


90.1 


92.6 


2.8 


9,9 


7,4 


-25.3 


Limited Ucenso Practitioners (LLP 


1 83.9 


86.1 


2.6 


16.2 


13.9 


-1 A 9 


Ootometrs/ 


90.0 


91 .4 


1.6 


10,0 


8.6 


-1 A n 


Chiropractic 


55.2 


57.5 


4.2 


44.8 


42.5 


-5.1 


Podiatry 


91.2 


93.4 


2.4 


8.7 


6.6 


-24.1 


Oral Surgery 


69.3 


77.1 


11.3 


30.7 


22.9 


-25.4 


lotai rnysicians (Mua, DOs and L 


86.4 


91 .0 


5.3 


13.6 


9.0 


-33.8 


Nonphysician Practitioners * 


83.8 


87,0 


3.8 


16,2 


13.0 


-19.8 


Suppliers 


97.3 


97,9 


0.6 


2.7 


2.1 


-22.2 


Portable X-Ray Supplier (Independent 


99.1 


99.3 


0.2 


0.9 


0.7 


-22.2 


Independent Laboratory 


96.1 


95.7 


-0.4 


3.9 


4.3 


10.3 


All Other Suppliers 


97.3 


98.6 


1.3 


2.7 


1.4 


-48.1 



Based on assigned allowed charges of participating and nonparticlpating physicians. 
^ Includes physicians (doctors of medicine (MDs), doctors of osteopathy (DOs), and limited license practitioners) (LLPs)- 

(optometrists, chiropractors, podiatrists and oral surgeons). Also includes nonphysician practitioners and suppliers. 
^ Includes radiation therapy and nuclear medicine specialties. 

* Includes audiologists, physical therapists, occupational therapists, and psychologists (billing HCPCS 90830). 
Excludes certified nurse-midwives, certified registered nurse anesthetists, nurse practitioners 
and clinical social workers. 

Based on summary data from the 1993 National Claims History for physicians' services incurred and processed from 
January through December 1 993. 



SOURCE: Bureau of Data Management and Strategy 



TABLE 3 



Assigned and Unassigned AJIowed Charges as Percent of TotaJ Allowed Charges, By Typo o« Service 



Type of Service ^ 



Assigned ' 



Anesthesia 
Standard Imaging 
Advanced Imaging 
Echography 
Imaging/Procedure 
Office Visits 
Hosprtal Visits 

Emergency Department Care 

Home/Nursing Home Visrts 

Specialist Visits 

Consultations 

Major Procedures General 

Major Cardiovascular Procedures 

Major Orthopedic Procedures 

Eye Procedures - Surgery 

Ambulatory Procedures 

Minor Procedures 

Oncology 

Endoscopy 

Dialysis 

Lab Tests 

Other Tests 

Assistant at Surgery 

Chiropractic 

Total ^ 



1992 
Percent of 

Total 
Allowed 
Charges 



80.2 % 

87.5 

90.3 

92.0 

91.1 

77.3 

89.2 

97.7 

92.4 

88.7 

88.2 

84.7 

90.3 

84.1 

91.2 

86.7 

86.6 

89.9 

86.1 

98.4 

94.4 

87.6 

86.6 

55.4 

86.5 



1993 
Percent of 

Total 
Allowed 
Charges 



89.7 % 

92.6 

94.3 

95.2 

95.4 

83.3 

93.1 

98.9 

94.8 

91 .6 

92.5 

91 .2 

94.6 

91 .5 

94.0 

91.6 

90.6 

94.3 

91 .3 

98.9 

96.9 

91.4 

92.7 

57.5 

91.1 



Percent 
Change 
1992-1993 




11.8 % 
5.8 
4.4 
3.5 
4.7 
7.8 
4.4 
1.2 
2.6 
3.3 
4.9 
7.7 
4.8 
8.8 
3.1 
5.7 
4.6 
4.9 
6.0 
0.5 
2.6 
4.3 
7.0 
3.8 

5.3 



1992 
Percent of 

Total 
Allowed 
Charges 



19.8 % 
12.5 

9.6 

7.9 

8.9 
22.7 
10.8 

2.3 

7.6 
11.3 
11.8 
15.3 

9.7 
15.9 

8.9 
13.3 
13.5 
10.1 
13.9 

1.6 

5.7 
12.5 
13.5 
44.7 

13.5 



1993 
Percent of 
Total 
Allowed 
Charges 



10,4 % 

7,5 

5.7 

4.8 

4.6 
16.6 

6.9 

1.1 

5.2 

8.4 

7.5 

8.8 

5.4 

8.5 

6.0 

8.4 

9.5 

5.6 

8.7 

1.1 

3.1 

8.7 

7.4 
42.5 

8.9 



Percent 
Change 
1992- 1993 



-47.5 % 
-40.0 
-40.6 
-39.2 
-48.3 
-26.9 
-36.1 
-52.2 
-31 .6 
-25.7 
-36.4 
-42.5 
-44.3 
-46.5 
-32.6 
-36.8 
-29.6 
-44.6 
-37.4 
-31.3 
-45.6 
-30.4 
-45.2 
-4.9 

-34.1 



Ba>ed on allowM charge* tor assigned servtces of participating and nonparflclpadng physielans/practltlonere. 

All type* of service except assistant at surgery' are based on procedure code grouping* developed by the Urban Institute. 

Type of service assistant at surgery' based on HCFA type of service code. 

Include* data for not otherwl** cla**ifled CPT and HCFA asdgned codas. 

B«*ed on lummary data from the 1993 National Claims HIatory for physician*' sarvicee incurrad and procaaaad from January through Oaeamber 1993. 
SOURCE: Bureau of Data Management and Strategy 



TABLE 4. 



Percent of Ass.gnea Allowed Charges for Partc.Dating Versus Nonoarticipating Physicians ana Percent of 

3y State 



Unassignod Allowed Charges, 



Particioating 
Physicians/Practitioners 



Nonparticioaong 
Physicians/Practitoners 



Percent of Total 
Allowed Charges 



1992 



1993 



Percent 
Change 

1992-1993 



Alabama 

Alaska 

Arizona 

Arkansas 

California 

Colorado 

Connecticut 

Delaware 

Olsthct of Columbia 

Florida 

Georgia 

HawiUI 

Idaho 

Illinois 

Indiana 

loMia 

Kansas 

Kentucky 

Louisiana 

Maine 

Maryland 

Massachusetts 

Michigan 

Minnesota 

Mississippi 

Missouri 

Montana 

Nebraska 

r4mad« 

New Hampshire 
New Jersey 
tXew Mexico 
New York 
North Carolina 
North Dakota 
Ohio 

Oklahoma 

Oregon 

Pennsylvania 

Rhode Island 

South Carolina 

South Dakota 

Tennessee 

Texas 

Utah 

Vermont 

Virginia 

Washington 

Wast Virginia 

Wisconsin 

Wyoming 

Puerto RICQ/ Virgin Islands 
Total ' 



S9.S % 

673 

73.3 

872 

75.1 

58.6 

77.8 

S4.S 

82.1 

77.5 

76.8 

336 

21 8 

68.7 

76.7 

64.2 

as.8 

80.2 
33.3 
84.5 
81.0 
92.6 
90.4 
30.1 
80.3 
83.1 
3S.8 
63.2 
94.8 
72.8 
57.2 
68.5 
88.7 
76.8 
53.7 
82.6 
58.2 
50.1 
95.8 
98.0 
75.1 
21.8 
85.0 
70.1 
78.7 
90.7 
79.5 
54.1 
88.8 
56.4 
30.8 

92.4 

75.0 



93.9 % 

73.4 

82.5 

91.3 

835 

71 4 

84.5 

88 0 

89.9 

86.1 

842 

as 3 

36.9 

78.9 

850 

75.0 

92.8 

86.1 

88.9 

90.8 

87.9 

99.6 

94.4 

41 .9 

86.0 

80.0 

57.1 

748 

96.8 

84.3 

68.4 

78.3 

72.7 

82.4 

54.6 

94.7 

72.6 

85.7 

97.4 

96.4 

83.1 

29.9 

69.0 

78.8 

88.8 

93.7 

88.0 

89.0 

93.9 

74.7 

56.7 

93.0 

83.0 



Assigned 



Percent 
Change 



1992 



1993 



1992-1993 



Unassigned 



Percent 
Change 



1993 j 1992-1893 



4 8 % 


5.4 % 


3.3 % 


-38.9 % 


4.9 % 


2.8 % 


j -42.9 % 


9.1 


21 6 


I 17.9 


-17,1 


11.1 


8.7 


1 ■21,8 


12,8 


79 


44 


-44,3 


18.8 


13.2 


1 ^29,8 


4.7 


6.2 


45 


•274 


66 


43 


■34,8 


11,2 


12.3 


8.6 


-30,1 


12.6 


7,9 


I -37 3 


28,1 


18.7 


12,5 


-33,2 


247 


18,0 


-35.2 


8,9 


11,6 


8,0 


-31,0 


10.6 


7,5 


-30.8 


5,3 


8.4 


56 


-33,3 


7,2 


5.4 


■25.0 


4,8 


6.6 


48 


-25.8 


11 4 


9.1 


-20.2 


11,1 


11 5 


7 7 


-33.0 


11,0 


8.2 


-43.6 


9.5 


10.8 


78 


-278 


12.3 


8.0 


-35.0 


6.8 


7 7 


5,2 


-32.5 


86 


5.5 


-36.0 


69 3 


15.4 


13,3 


-13 6 


62.7 


48.8 


■20 8 


18.3 


12.2 


8,3 


-32.0 


21.0 


12.8 


■38.0 


10.8 


7 8 


5.3 


■32.9 


15.9 


97 


-37.4 


16.8 


8.3 


6.0 


-27.7 


274 


19.0 


■30.7 


3.3 


2.9 


2.0 


-31 0 


7 3 


5.3 


■27 4 


9.9 


9.4 


6.1 


-35.1 


10.3 


5.8 


■43.7 


4.3 


8.5 


7.4 


-12.9 


8.3 


5.7 


-31 3 


75 


10.9 


5.9 


-45.9 


46 


3.3 


-28.3 


8.9 


12.2 


6.8 


■443 


68 


5.3 


-22.1 


3.2 


69 


3.9 


-43.9 


06 


0.6 


0.0 


4.4 


4.5 


2.9 


-39.6 


5.0 


2.8 


-440 


38.2 


16.3 


13.8 


-15.3 


53.6 


44.3 


-17.4 


7.1 


10.7 


79 


-26.2 


8.1 


8.0 


■34.1 


26 8 


18.2 


9.2 


-48.5 


18.7 


10.8 


-42.2 


43.9 


18.3 


12.8 


■30.1 


41 9 


30.1 


-28.2 


18.4 


74 


48 


-35.1 


29.5 


20.4 


•30.8 


1.3 


3.8 


2.7 


■25.0 


1.8 


1.5 


-18.7 


16.1 


12.7 


7.1 


■44.1 


14.7 


8.8 


•41,5 


18.1 


18.5 


15.4 


-18.8 


24.3 


18.2 


•25,1 


14.3 


15.5 


11.3 


-27.1 


16 1 


10.4 


•35.4 


90 


176 


14.7 


-18.5 


15.7 


12.6 


•19.7 


7.3 


10.2 


8.0 


-21 .6 


1 3 0 


9.6 


•26.2 


1.7 


9.8 


9.6 


0.0 


36.8 


35.8 


•2.7 


14.6 


8.0 


4.0 


■50.0 


9.4 


1.3 


-88.2 


24.7 


15.3 


10.0 


-34.8 


28.5 


17.4 


•34.3 


31.1 


19.4 


12.1 


-21,4 


346 


22.2 


-39.8 


1.7 


3.0 


1.7 


-433 


1.2 


0.9 


-25.0 


0.4 


1.6 


1.3 


-18,7 


0.5 


0.4 


-20.0 


10.7 


13.1 


8.7 


-33,6 


11.9 


as 


-31.1 


38.4 


13.9 


11.4 


-15.6 


64.8 


58.7 


•9.6 


58 


74 


5.0 


-32.4 


78 


5.1 


•32.8 


12.1 


14.1 


10.4 


-26.2 


15.6 


11.0 


-30.4 


10.0 


6.8 


5.0 


•24.2 


14.7 


8.3 


-43.5 


3.3 


6.2 


4.2 


-32.3 


3.1 


2.1 


-32.3 


10.7 


10.0 


S.9 


-41.0 


10.5 


6.1 


•41.9 


279 


14.2 


9.3 


-34.5 


31 7 


21 8 


-31.2 


5.5 


7.9 


4 2 


-447 


3.8 


2.3 


•39.9 


32.4 


174 


9.6 


■44.8 


28.2 


15.6 


•40.9 


39.9 


14.3 


10.0 


■30.1 


48.0 


34.4 


•25.2 


0.6 


85 


8.0 


-7.7 


1.2 


1.0 


•18.7 


10.7 


11.5 


8.1 


-29.8 


13.5 


8.8 


•34.1 



' Include* aHowvd charge data for physicians' services for Railroad Hettrement Board claims. 
Based on summary data from the 1883 Natlonai Claims History for physicians' services incurred and procesaad from January through Oecamber 1983. 
SOUIWE: Bureau ol Data Management and Strategy 



TABLE 5 



Percent of Ass.gnea Allowed Charges for Part.cpa.mg Versus Nonpartic.pat.ng Physicians ana Percen. of Unassigned Allowed Charges 

ay Specialty 



Specialty 


Participating 
Physicians/practiti 


sners 


i 

1 




Nonparticipating 
Physicians/practitioners 




Percer 
Allowe 


t of Total 
j C harqes 


ercent 
Change 

1 1 yy J 


Assigned 


i 1 
1 Unassigned | 


1992 


1993 


Percent of Total 
Allowed Charges 


Percent 
Change 
1 992-1 993 


Percent of Total 
Allowed Charges 


Percent 
Change 
1982-1993 

i 


1SS2 


1993 


1992 


1993 1 1 


All Specialtlaa ■ 


75.0 % 


83.0 % 


1 0 7 % 


11,5% 


8.1 % 


-28.6 % 


13.5 % 


3.9 % 


■34.1 % 


Phyilclant (M0> and 00a) 


75.3 


83.3 


10 6 


1 1.2 


7 9 


-29.9 


13.8 


8.8 


■35.3 


Family Practice 


85.7 


74.8 


13.5 


14,0 


10.9 


-22.1 


20.3 


14.5 


■28.8 


General Practice 


73.5 


79.5 


8 2 


12,7 


10.9 


-14.2 


13.8 


9.8 


■30.4 


Cardiology 


80.3 


87.9 


9.9 


9,7 


6.1 


-37.1 


10.0 


8.0 


■40.0 


Dermatology 


74.9 


82.2 


9 7 


8,9 


9.7 


-38.0 


18.2 


1 2 1 


■25.3 


Internal Medicine 


87.0 


79.9 


13.3 


14,3 


10.8 


-24.9 


18.7 


13.3 


■28.9 


Gastroenterology 


79.8 


86.8 


8.8 


10 0 


6 4 


-36.0 


10.2 


8.8 


-33.3 


Nephrology 


86.0 


89.2 


1 T 

J. / 


9.2 


7.3 


-20.7 


4 8 


3.4 


■29.2 1 


Neurology 


71 .9 


80.2 


1 1 it 

11.9 


15.4 


11.5 


-25.3 


12.7 


8.3 


■34.6 


Obstetrics-Gynecology 


87.8 


74.9 


10.9 


1 3.8 


11.7 


-19.2 


1 6.4 


13.4 


■27.2 


Psychiatry 


70.8 


75.9 


7.2 


19.8 


16.3 


-1 7.7 


9.4 


7.9 


■18.0 i 


Pulmonary 


78.0 


88.8 


11.0 


12.2 


7,8 


-36.1 


9.8 


5.7 




U rology 


89.3 


80.8 


18.8 


1 1 4 


7,3 


-36.0 


19.3 


1 1.9 


-4 1.8 j 
■38.3 1 


Anestheelology 


85.8 


80.7 


22.8 


14.1 


8.8 


-37.6 


20.2 


10.5 


■48.0 1 


Pathology 


82.8 


89.5 


8. 1 


8.3 


9.0 


-39.6 


8.9 


9.9 


-38.2 


Radiology ' 


82.9 


90.0 


8.6 


7,3 


4 9 


■38.4 


9.8 


5.4 


■44.9 ' 


General Surgery 


79.4 


87.7 


10.9 


9.8 


6.3 


-36.4 


10.8 


6.0 


•44.4 ! 


Neurosurgery 


72.8 


82.5 


13.3 


1 1.8 


8.9 


-24.8 


15 3 


8.6 


■43.8 


Ophthalmology 


80.7 


88.9 


7.7 


8.9 


9.9 


•33.7 


10.4 


7 2 


-30.8 


Orthopedic Surgery 


73.4 


85.3 


16.2 


10.7 


8.3 


-41.1 


15.6 


8.4 




Otolaryngology 


88.8 


78.9 


13.4 


12.5 


8.9 


-28.8 


18.0 


1 2.3 


■47.2 j 
■31.7 1 


Plastic Surgery 


75.8 


83.8 


10.6 


13.2 


9.9 


-28.0 


1 1.0 


8 8 


■40.0 


Thoracic Surgery 


81.2 


87.8 


8. 1 


8.6 


9.6 


•31.4 


10.1 


8.3 


■37.8 


Clinic or Other Group Practice 


78.9 


87.2 


10.9 


9.8 


8.8 


-30.6 


1 1.2 


8.0 


■48.4 


All Other Physician! 


77.9 


84.0 


7.8 


12.2 


8.7 


•26.7 


9.9 


7,4 


•29.3 


Limited LIcansa Practltlonart (LLPs) 


72.7 


77,0 


9.9 


11.2 


9.1 


•18.7 


18.2 


13.9 


I 

■14.2 


Optometry 


81.7 


84.4 


3.3 


8.3 


7.0 


•19.7 


10.0 


8,8 


•14.0 1 


Chiropractic 


43.2 


46 2 


8.8 


12.0 


11.3 


-5.8 


44.8 


42.5 


■5.1 1 


Podiatry 


78.8 


84.7 


8.0 


1 1.3 


8.7 


•23.0 


8.7 


6 6 


•24.1 


Oral Surgery 


46.3 


58.9 


22 9 


23 0 


20.2 


•12.2 


30.7 


22.9 


•29.4 


Total Phyalclana (MOe, DOa and LLPs) 


75.2 


83.1 


10.9 


11.2 


7.8 


-29.9 


13.6 


9.0 


■33.8 


Nonphyelclan Practltlonart ' 


48.3 


84.0 


32.9 


39 9 


23.0 


-35.2 


18.2 


13.0 


-19.8 


SuppMare 


72.0 


85.2 


18.3 


29.3 


12.7 


-46.8 


2.7 


2.1 


-22.2 1 


Portable X-Ray Supplier (Indapandant) 


7S.9 


87 2 


19.9 


23.8 


12.1 


-48.7 


0.9 


0.7 


•22.2 


Independent Laboratory 


71.0 


84.8 


18.4 


29.1 


10.9 


-98.6 


3.9 


4.3 


10.3 


All Other Suppliers 


70.8 


84.2 


19.3 


26 7 


14.4 


-48.1 


2.7 


1.4 


•48.1 



' Includes physicians (doctors of medicine (M0*|. doctors al oetaopathy (OOs), and limited license practitioners) (LLPs) • 

(optometrists, chiropractors, podiatnsti and oral surgeons). Also inciudee nonphysician practitioners and suppliers. 
' Includes radiation therapy and nuclear medicine spacialtta*. 

' Includes audlologists, physical therapists, occupational therapists, and psychologists (billing HCPCS 90830). 
Excludes certified nurse^midwives, certified registered nuree anesthetists, nurse practitioners and clinical social workers. 

Saiad on summary data from the 1983 National Claims History for physicians' sarvlcaa incurred and processed from January through Oaeamber 1983. 
SOURCE : Bureau ol Data Management and Stratagy ' 



TABLE 6 

Percent of Assigned Allowed Cfiarges for Participating Versus fvlonparticipating Pfiysicians and Percent of Unassigned Allowed Charges, 

By Type of Service 



Type of Service ^ 


Participating 
Physicians/Practitioners ' 




Nonparlicipating Physicians/Practitioners 




ABst{pied SeivtcM 


Linaeslgned 


1992 
Percent 
of Total 
Allowed 
Charges 


1993 
Percent 
of Total 
Allowed 
Charges 


Percent 
Change 
1992-1993 


1992 
Percent 
of Total 
Allowed 
Cfiarges 


1993 
Percent 
of Total 
Allowed 
Charges 


Percent 
Change 
1992-1993 


1992 
Percent 
of Total 
Allowed 
Charges 


1993 
Percent 
of Total 
Allowed 
Charges 


Percent 
Chtinge 
1992- 1993 


Anestfiesia 


66.0% 


80.8 % 


22.4% 


14.2 % 


8.9 % 


-37.3 % 


19.8 % 


10.4 % 


-47.5% 


Standard Imaging 


78.4 


86.8 


10.7 


9.1 


5.8 


-36.3 


12.5 


7.5 


-40.0 


Advanced Imaging 


81.4 


89.1 


9.5 


8.9 


5.2 


-41.6 


9.6 


5.7 


^0.6 


Echography 


81.4 


88.1 


8.2 


10.6 


7.1 


-33.0 


7.9 


48 


-39.2 


Imaging/Procedure 


82.8 


90.7 


9.5 


83 


4.7 


-43.4 


8.9 


46 


-48.3 


Office Visits 


67.7 


75.9 


12.1 


96 


7.4 


-22.9 


22.7 


16 6 


-26.9 


Hospital Visits 




CMJ.O 




ICQ 


IOC 


-25.0 


10.8 


6.9 


-36.1 


Emergency Department Care 


89.5 


929 


3.8 


8.2 


6.0 


-26.8 


2.3 


1.1 


-52.2 


Home/Nursing Home Visits 


73.1 


80.8 


10.5 


19.3 


14.0 


-27.5 


7.6 


5.2 


-31.6 


Specialist Visits 


77.6 


83.5 


7.6 


11.1 


8.1 


-27.0 


11.3 


84 


-25.7 


Consultations 


75.0 


83.1 


10.8 


13.2 


9.4 


-28.8 


11.8 


75 


-36.4 


Major Procedures General 


73.1 


83.4 


14.1 


11.6 


7.8 


-32.8 


15.3 


8.8 


-;2.5 


KAainr r^ArHi/^unfu^iilAr PmPAHlirAft 

IVKUVI ^CIIUIWOOl'UICII l^iV/W\JUIw9 


81.3 


89.0 


9.5 


9.0 


5.6 


-37.8 


9.7 


5.4 


-44.3 


Mc^r Ortfiopedic Procedures 


72.5 


84.5 


16.6 


11.6 


7.0 


-39.7 


15.9 


8.5 


-46.5 


Eye Procedures - Surgery 


81.3 


87.5 


7.6 


9.9 


6.5 


-34.3 


8.9 


60 


-32.6 


Ambulatory Procedures 


75.4 


83.9 


11.3 


11.3 


7.7 


-31.9 


13.3 


8.4 


-36.8 


Minor Procedures 


75.0 


82.1 


9.5 


11.6 


8.5 


-26.7 


13.5 


9.5 


-29.6 


Oncology 


81.0 


88.7 


9.5 


8.9 


5.6 


-37.1 


10.1 


56 


-44.6 


Endoscopy 


75.4 


84.4 


11.9 


10.7 


6.9 


-35.5 


13.9 


8.7 


-37.4 


Dialysis 


88.2 


91.1 


3.3 


10.2 


7.8 


-23.5 


1.6 


1.1 


-31.3 


Lab Tests 


79.1 


88.0 


11.3 


15.3 


8.9 


-41 .8 


5.7 


3.1 


-45.6 


Other Tests 


74.4 


82.2 


10.5 


13.2 


9.2 


-30.3 


12.5 


87 


-30.4 


Assistant at Surgery 


72.5 


83.0 


14.5 


14.1 


9.7 


-31.2 


13.5 


7.4 


-45.2 


Chiropractic 


43.4 


46.2 


6.5 


12.0 


11.3 


-5.8 


44.7 


42,5 


-4.9 


Total* 


75.0 


83.0 


10.7 


11.5 


8.1 1 


-29.6 


13.5 1 


8.9 


-34.1 



' Include* physicians (doctofs of medlclna (MDs), doctors of osteopathy (OOs), and limited license practitioners) (LLPs)- 
(optometrlsts, chiropractors, podiatrists and oral surgeons). Also Includes nonphysician practitioners and suppliers. 

' All types of service except assistant at surgery' are based on procedure code groupings developed by the Urban Institute. 
Type of service 'assistant at surgery' based on HCFA type of service code. 

' Includes data for not otherwise classMad CPT codas and fiCFA assigned codes. 



Based on summary data from the 1993 National Claims History for physicians' services Incurred and processed from January through December 1993 
SOURCE Bureau of Data Management and Strategy 



TABLE 7 



Medicare Percent of Participating Physicians. Practitioners and Suppliers 



Specialty 


Participation Percentage 


j 

Percent 


Jflniiflrv 1 1 QO^ 


January 1 , 1 994 


Change 


Total Physicians (MDs, DOs and LLPs) 


RO n 

O^.U "to 


66.7 % 


7.6 % 


Medical Doctors (MOs) and Doctors of Osteopathy (DOs) 


67 3 


71 .9 


6.8 


General Practice 


55.1 


39.1 


7.2 


General Surgery 


73.9 


f f.f 


4.3 


Otolaryngology 


66.2 




9.0 


Anesthesiology 




/I .5 


10.6 


Cardiology 


7R 7 

f O. I 


82.5 


4.8 


Dermatology 




fO.O 


8.5 


Family Practice 




71 .3 


7.9 


Internal Medicine 


oo.*t 


71 .3 


7.4 


Neurology 


71 ft 

f 1 .o 


76.4 


6.4 


Obstetrlcs-Qynecology 


DO./ 


69.9 


6.S 


Ophthalmology 


7*^ 5 


78.3 


7.0 


Orthopedic Surgery 


74 Q 




5.8 


Pathology 


73.3 


fO.O 


4.8 


Psychiatry 


53.5 


Of .O 


8.1 


Radiology 


74.7 


lO.O 


5.1 


Urology 


71 .8 


7A A 


9.5 


Nephrology 


82.4 




2.3 


Clinic or Other Group Practice 


75.5 




6.6 


Gastroenterology 


78.8 




5.8 


Pulmonary 


78.7 


83.5 


6.1 


Neurosurgery 


72.1 


76.9 


6.6 


Plastic Surgery 


71 .3 




6.5 


Thoracic Surgery 


79.0 




5.4 


Rheumatology 


68.0 


T*? A 
r O.O 


O.O 


Vascular Surgery 


85.0 


A7 A 

Of .o 


3.3 


Cardiac Surgery 


81.1 


84.3 


4.0 


Hematology/Oncology 


76.0 


84.1 


10.7 


Radiation Oncology 


81.8 


84.9 


3.8 


Emergency Medicine 


78.6 


82.1 


4.4 


All Other Physicians 


54.5 




3.5 


Limited License Practitioners (LLPs) 


38.6 


AO ft 


10.9 


Chiropractic 


35.6 


09.0 


11.8 


Podiatry 


70.9 


75.3 


6.2 


Optometry 


BP 7 


DO.O 


4.6 


Oral Surgery 


14.1 


16.4 


16.5 


Nonphysician Practitioners 


44.0 


51.7 


17.5 


Certified Nurse-Midwife 


51.0 


58.7 


15.1 


Certified Registered Nurse Anesthetist 


43.8 


55.1 


25.8 


Physical Therapist (Independent) 


50.1 


57.0 


13.7 


All Other Non-physician Practitioners 


43.4 


50.3 


15.9 


Total Physicians and Non-physician Practitioners 


59.8 


64.8 


8.4 



NOTE: The 1993 Total MDs/DOs" and "All Other Physicians* figures on this table differ slightly from the 1993 figures provided in last 
year's report. This is due to our decision this year to exclude ambulatory surgical centers, public health and welfare agencies, 
and voluntary health or charitable agencies from the MD/DO/Physician category for this analysis. 



SOURCE: Bureau of Program Operations, Contractor Reporting of Operational and Workload Data (CROWD) as of May 1 0, 1994 



TABLE 8 



1994 Physician/Practitioner Enrollment, By State 





January 1 ,1993 


January 1 , 1994 


Percent 


State 


Participation 


Participation 


Change 




Percentage 


1 Percentage 


1993-1994 


1 

1 National* 

i 


59.8 % 


64.8 % 


8.4 % 


^ A t a fc^ a m a 


85.1 


87.2 


2.5 


Alaska 


60.4 


66.3 


9.8 


Arizona 


76.2 


82.6 


8.4 


1 Arkansas 


62.1 


64.9 


4.5 


Califo rnia 


65.9 


69.0 


4.7 




55.7 


58.5 


5.0 


Connocticut 


55.4 


57.8 


4.3 


Odiawara 


57.4 


60.0 


4.5 


UlSiriCl OT ^OIUiTiDIa 


50.6 


52.8 


4.3 


rionaa 


55.6 


62.2 


11.9 


QaofQia 


74.9 


82.7 


10.4 


Hawaii 


75.9 


80.4 


5.9 


loano 


37.1 


49.7 


34.0 


Illinois 


57.6 


61.8 


7.3 


Indiana 


55.8 


61.3 


9.9 


Iowa 


61 ,0 


63.2 


2.3 


1^ A n A O A 

rvansas 


73.2 


78.7 


7.5 




rO.B 


68.1 


•6.4 


1 All i ci ana 


44.0 


46.7 


6.1 


Mai no 


9Z.U 


53.6 


3.1 


iViarytana 


7Z.5 


77.3 


6.6 


Massachusdtts 


50.2 


48.9 


-2.6 


Michigan 


58.1 


62.1 


6.9 


Minnesota 


44.4 


51.3 


15.5 


Mississippi 


53.4 


53.8 


0.7 


Missouri 


67.5 


81.8 


21.2 


Montana 


54.7 


58.7 


7.3 


Neoraska 


70.8 


75.9 


7.2 


Nevada 


84.9 


87.9 


3.5 


Now Hampshiro 


43.0 


48.0 


11.6 


New Jersey 


42.6 


45.9 


7.7 


New Mexico 


DO.O 


74.2 


11.1 




Art 7 
40.7 


46.2 


13.5 


North Carolina 


72.8 


76.9 


5.1 


iNortn uakota 


55.0 


77.4 


40.7 


unio 


76.6 


83.3 


8.7 


Oklahoma 


53.9 


64.9 


20.4 


Oregon 


59.2 


66.5 


12.3 


Pennsylvania 


59.7 


61.1 


2.3 


nnooe isiano 


80.9 


82.2 


1.6 


ooutn uaroiina 


67.3 


70.2 


4.3 


eolith r^nLr^v^H 

boutn uaKota 


31 .6 


41.2 


30.4 


TennesM6 


70.5 


76.9 


9.1 


Texas 


OI.3 


68.6 


11.9 


Ulan 


BII.3 


82.0 


2.1 


Vermont 


56.8 


58.8 


4.1 


Virginia 


52.2 


52.9 


1.3 


Washington 


64.7 


73.9 


14.2 


West Virginia 


75.9 


81.9 


7.9 


Wisconsin 


66.8 


73.7 


10.3 


Wyoming 


53.3 


63.0 


18.2 



* Include* Puarto Rico and th* Virgin Itlandi 



SOURCE: Bureau ol Program Oparatlont, Contractor Reporting of Operational and Workload Data (CROWD), 
at of May 10, 1S94 



TABLE 9 

Extra Billing Ratea For Unassigned Allowed Charges By Nonparticipants, By State 





1 QQO 


1 993 






Ratio of 


Ratio of 


Percent 




extra ttiiing 


Extra Billing 


Change 


to AJlowed 


to Allowed 


' 1992- 1993 




Charges 




Charges 




Total ^ 




16.7 


-26.8 % 


Alabama 


22.2 


15.2 


-31.5 


Alaska 


28.0 


19.0 


-32.1 


Arizona 


21.8 


15.6 


-28.4 


Arkansas 


20.8 


15.1 


-27.4 


California 


24.6 


18.5 


-24.8 


Colorado 


22.0 


16.2 


-26.4 


Connecticut 


22.3 


16.0 


-28.3 


Delaware 


19.5 


13.6 


-30.3 


District of Columbia 


23.3 


17.4 


-25.3 


Florida 


21 .0 


15.1 


-28.1 


Georgia 


23.2 


16.8 


-27.6 


Hawaii 


28.6 


19.4 


-32.2 


Idaho 


21.5 


15.8 


-26.5 


Illinois 


22.8 


16.3 


-28.5 


Indiana 


21.0 


14.8 


-29.S 


Iowa 


20.7 


14.9 


-28.0 


Kansas 


20.3 


14.5 


-28.6 


Kentucky 


20.9 


14.5 


-30.6 


Louisiana 


21.4 


15.6 


-27.1 


Maine 


21,1 


15.1 


-28.4 


Maryland 


21.9 


15.6 


-28.8 


Massachusetts 


19.5 


12.1 


-37.9 


Michigan 


21.3 


14.3 


-32.9 


Minnesota 


22.1 


16.0 


-27.8 


Mississippi 


25.4 


16.6 


-34.6 


Missouri 


21.5 


15.2 


-29.3 


Montana 


22.2 


16.1 


-27.5 


Nebraska 


21.2 


15.0 


-29.2 


Nevada 


24.1 


17.4 


-27.8 


New Hampshire 


21.8 


15.2 


-30.3 


New Jersey 


23.1 


17.5 


-24.2 


New Mexico 


22.7 


15.6 


-31.3 


New York 


27.3 


20.7 


-24.2 


North Carolina 


21.3 


15.5 


-27.2 


North Dakota 


22.4 


16.7 


-25.4 


Ohio 


22.2 


11.4 


-48.6 


Oklahoma 


22.1 


15.6 


-29.4 


Oregon 


22.3 


16.3 


-26.9 


Pennsylvania 


11.1 


7.2 


-35.1 


Rhode Island 


27.4 


10.5 


-61.7 


South Carolina 


21.5 


14.6 


-32.1 


South Dakota 


21.5 


15.6 


-27.4 


Tenne«se« 


21.5 


15.1 


-29.8 


Texas 


23.0 


17.3 


-24.8 


Utah 


22.9 


17.2 


-24.9 


Vermont 


19.4 


13.1 


-32.5 


Virginia 


22.0 


14.9 


-32.3 


Washington 


22.4 


16.2 


-27.7 


West Virginia 


22.8 


14.9 


-34.6 


Wisconsin 


21 .2 


15.5 


-26.9 


Wyoming 


21.5 


15.6 


-27.4 


Puerto Rico/Virgin Island* 


19.7 


13.2 


-33.0 



' Extrm billing It th* dM*r*nc« b*tv>Mn tha aubmincd charge and tha allowad charg* 

for unaaalgnad claimt. Excluda* unatiignad charge* fo; daniad sarvica*. 
' Includaa unasslgnad chargea for Railroad Ratlramant S^ard 



Based on summary data from the 1993 National Claims History for physicians' services 
incurred and processed from January through December 1993. 



SOURCE: Bureau of Data Management and Strategy 



TABLE 10 



Extra Billing Rates For Unassigned Allowed Charges by Nonparticipants, By Specialty 





I Ratio of Extra Billing ' 


Percent 




1 to Allowed Charges 


Change 


Specialty 




T 


' 1 992 - 1 993 




■ 


1992 


1993 


I 


All Specialties ^ 


22.8 


16,7 


-26.8 % 


Physicians (MOs and OOs) 


23.0 


16.9 


-26.5 


Family Practice 


20.1 


14.7 


-26.9 


General Practice 


20.0 


14.6 


-27.0 


Cardiology 


23.0 


16.0 


-30.4 


Dermatology 


19.9 


14.7 


-26.1 


Internal Medicine 


20.9 


15.2 


-27.3 


afitrn AntArrtl^nu 


22.1 


16,1 


-27.1 


Nephrology 


22.4 


16.5 


-26.3 


Neurology 


22.4 


15.7 


-29.9 


Obstetrics-Gynecology 


33.0 


21.5 


-34.8 


Psychiatry 


23.9 


15.6 


-34.7 


Pulmonary 


21.2 


15.6 


-26.4 


Urology 


23.8 


17.4 


-26.9 


Anesthesiology 


31.3 


34.0 


8.6 


Pathology 


22.4 


15.9 


-29.0 


Radiology ^ 


22.0 


16.0 


-27.3 


GenersI SurnArv 


26.9 


20.1 


-25.3 


Neurosurgery 


28.8 


20.8 


-27.8 


Ophthalmology 


20.7 


15.3 


-26.1 


Orthopedic Surgery 


25.1 


18.8 


-25.1 


Otolaryngology 


25.2 


17.5 


-30.6 


Plastic Surgery 


41 .6 


28.3 


-32.0 


Thoracic Surgery 


27.0 


18.1 


-33.0 


Clinic or other group practice 


24.9 


17.8 


-28.5 


All AthAf nh\/sif*ifln4k 
mi wiiioi |i/iiy 9IUICU19 


22.1 


15.7 


-29.0 




16.3 


10.7 


-34.4 


Optometry 


6.9 


5.7 


-36.0 


v^niropracuC 


13.7 


9.0 


-34.3 


Podiatry 


17.8 


12.0 


-32.6 


Oral Surgery 


63.8 


49.2 


-22.0 


Total Physicians (MDs, OOs and LLPs) 


22.7 


16.5 


-27.3 


Non physician Practitionars * 


36.3 


34.0 


-6.3 


Suppliers 


32.5 


29.6 


-8.9 


Portable X-Ray Supplier (Independent) 


40.7 


36.4 


-10.6 


Independent Laboratory 


25.2 


16.3 


-35.3 


All Other Suppliers 


43.6 


57.1 


31.0 



Extra billing Is the difference between the submitted charge and the allowed charge on unassigned claims. 
Excludes submitted charges for unassigned services that were denied. 

Includes physicians (doctors of medicine (MOs), doctors of osteonathy (OOs), and llmitad license practitioners (LLPs), 

nonphysiclan practitioners and suppliers. 

includes radiation therapy and nuclear medicine specllaitles. 

Includes audlologlsts, physical therapists, occupational therapists, and psychologists (billing HCPCS 90830). 
Excludes certified nurse midwives, certified registered nurse anesthetists, nurse practitioners and clinical social workers. 

Based on sum mary data from the 1993 National Claims History for physicians services incurred and processed 
from January through December 1993 

SOURCE: Bureau of Data Management and Strategy 



TABLE 1 1 

Extra Billing Rates For Unassigned Allowed Charges By Nonparticpants, 

By Type of Service 



Ratio of Extra Billing ' Percent 
to Allowed Charges Change 



Type of Service ^ 


1QQ9 


lyyo 


1 

1992-1993 


Anesthesia 


O 1 .«7 


o4.o 


9.1 % 


Standard Imaging 


P1 fi 
£. 1 .U 


ID. 1 


-25.5 


Advanced Imaging 




ID.O 


-25.0 


Echography 


22.1 


1(^ Q 




Imaging/Procedure 


29.8 


1Q n 

1 9.0 


-oo.b 


Office Visits 


1Q n 


Tt, 1 


-25.8 


Hospital Visits 


21.1 






Emergency Department Care 


23.8 


1fi Q 


9Q n 


Home/Nursing Home Visits 


19.4 


1*? T 


-O 1 


Specialist Visits 


18.6 


14 1 




Consultations 


20.8 






Major Procedures General 


28.7 


20 Q 




Major Cardiovascular Procedures 


26.6 


18.5 


-30.5 


Major Orthopedic Procedures 


25.3 


19.9 


-21.3 


Eye Procedures - Surgery 


23.0 


16.5 


-28.3 


Ambulatory Procedures 


31.0 


21.6 


-30.3 


Minor Procedures 


25.1 


18.1 


-27.9 


Oncology 


23.1 


16.2 


-29.9 


Endoscopy 


24.0 


17.7 


-26.3 


Dialysis 


27.8 


20.9 


-24.8 


Lab Tests 


29.7 


21.7 


-26.9 


Other Tests 


26.7 


18.0 


-32.6 


Assistant at Surgery 


44.4 


30.1 


-32.2 


Chiropractic 


13.7 


9.0 


-34.3 


Total ' 


22.8 


16.7 


-26.8 



Extra billing ia the difference between the aubmitted charge and the allowed charge on 

unassigned claims. Excludes submitted charges for denied services. 
^ All typos of service (TOS) except 'assistant at surgery' are based on procedure code groupings 

developed by the Urban Institute. See Appendix for additional TOS descriptions. 

Type of sen/ice 'assistant at surgery' based on HCFA type of sen/ice code. 
^ Include* data for not otherwise classified OPT codes and HCFA assigned codes. 

Based on summary data from the 1993 National Claims History for physicians' services 
incurred and processed from January through December 1993. 

SOURCE: Bureau of Data Management and Strategy 



/ 



TABLE 12 



National Summary by Age. Race and Sex 



Characteristcs 


Assigned Services for 
Participating and Non-participating 
Physicians/Practitioners 


Unassigned Services 
Nonparticipating Physicians/Practitioners 




Assignment 
Rsto 


Percent 
Change 

1992-1993 


_ 

Ratio of Extra Billing Charges 
to Total Allowed Charges 


Percent 
Change 

1992-1993 


1992 


1993 


1992 


1993 


All Davmaha 

All rersons 


86.8%* 


91 .3 % * 


5.2 % 


23.5 * 




1- 

-23.8 % 


Male 


86.5 




91.3 


5.5 


23.9 


18.2 


-23.8 


Female 


87.1 




91 .4 


4.9 


23.2 


17.7 


-23.7 


White 


85.7 




90.6 


5.7 


23.4 




-Z3.9 


Black 


96.6 




97.8 


1.2 


24.4 


1 A Q 


-22.5 


Other 


86.4 




91.2 


5.6 


25.5 




-2S.9 


Unknown Race 


92.2 




94.9 


2.9 


25.2 


19.1 


-24,2 


Aged (MSC 1 0) 


85.9 




90.7 


S.6 


23.3 


17.7 




65 - 74 Years 


85.1 




90.2 


6.0 


23.7 


17.8 




75 - 84 Years 


86.1 




90.8 


5.5 


23.0 


17.5 


-23.9 


85 Years & over 


88.3 




92.1 


4.3 


22.9 


18.0 


-21.4 


Disabled (MSC 20) 


94.2 




96.3 


2.2 


27.7 


21.9 


-20.9 


Under 45 Years 


96.6 




97.7 


1.1 


30.9 


23.9 


-22.7 


45 - 54 Years 


94.9 




96.6 


1.8 


29.0 


22.4 


-22.8 


55 - 64 Years 


92.6 




95.3 


2.9 


26.4 


21 .0 


-20.5 


ESRD (MSC 11,21,31) 


97.0 




98.2 


1.2 


29.4 


25.3 


-13.9 


Under 25 Years 


98.9 




99.3 


0.4 


38.7 


28.6 


-26.1 


25 - 44 Years 


98.1 




98.9 


0.8 


33.1 


27.7 


-16.3 


45 - 64 Years 


97.4 




96.5 


1.1 


32.2 


28.2 


-12.4 


65 and over 


96.2 




97.6 


1.5 


27.3 


23.5 


-13.9 



* Note: These totals differ slightly from data presented elsewhere in the report because they are derived from a different data collection. 



Based on line item quarterly data from the National Claims History for physicians' 
services incurred and processed from January through December for 1992 and 1993. 

SOURCE: Bureau of Data Management and Strategy 



/ 



ens LIBRARy 




3 flDTS 0Q0iaDL3 1