Page 1 GAO-14-56R Medicaid Payment Rates

441 G St. N.W.

Washington, DC 20548

January 6, 2014

Congressional Committees

Medicaid: Use of Claims Data for Analysis of Provider Payment Rates

Within the Medicaid program, federal law requires that state Medicaid payments to providers be 

consistent with efficiency, economy, and quality of care; and be sufficient to enroll enough providers 

so that services are available to beneficiaries at least to the extent that they are available to the 

general population in the same geographic area.1

Two frequently cited studies of Medicaid payments have been conducted by the American 

Academy of Pediatrics (AAP) and the Urban Institute, both of which obtained state-specific fee 

schedule data for selected services and procedures through surveys of state Medicaid officials and 

from state websites.2

We prepared this report under the authority of the Comptroller General to conduct work on GAO’s 

initiative to assist Congress with its oversight responsibilities for the Medicaid program. In this 

report, we provide information on: (1) the extent to which state Medicaid programs vary the rates 

paid to providers for a given service and the basis for the variation; and (2) the extent to which 

Medicaid provider payment rates calculated from claims data confirm rates reported in studies of 

states’ fee schedules.

These studies shed some light on potential Medicaid payments for selected 

services; however, they provide little information on the extent to which states vary their payment 

for a service based on the circumstances in which that service was provided—such as whether the 

state pays a different amount depending on characteristics of the provider, setting, or beneficiary. 

These studies also provide little information on how often the payment rates they selected from the 

fee schedules were actually used in practice. Without such information, it may be difficult for the 

Centers for Medicare & Medicaid Services (CMS)—the agency within the Department of Health and 

Human Services that oversees the joint federal-state Medicaid program—or other policy makers to 

fully assess the adequacy of Medicaid payments. One potentially useful source of more 

comprehensive information on provider payments is claims data. Assessing Medicaid fee schedules 

against Medicaid claims data can serve to cross validate both data sources, and provide new 

insights into the robustness of claims data for payment analyses.

Scope and Methodology

To conduct this work, we examined 2010 Medicaid fee-for-service (FFS) claims data for selected 

professional services and states. We selected 35 professional services from among those included 

in the studies by the AAP and the Urban Institute. The services were chosen to represent a range of 

professional service categories—including evaluation and management, imaging, laboratory, and 

maternal health. We selected 9 states from among the 26 states with available 2010 claims data as 

of October 2012. We chose states that represented different regions of the country and that served 

 1

See 42 U.S.C. § 1396a(a)(30)(A).

2

American Academy of Pediatrics, Medicaid Reimbursement Survey, 2010/11, American Academy of Pediatrics (Elk 

Grove, IL, 2011). Zuckerman S. et al., Trends in Medicaid Physician Fees, 2003-2008, (Washington, D.C.: Health Affairs, 

Vol. 28, No.3, 2009), w510-w519. 
Page 2 GAO-14-56R Medicaid Payment Rates

a relatively large proportion of their Medicaid population through FFS arrangements rather than 

through managed care.3

To determine the extent to which state Medicaid programs varied the rate they paid for a given 

service, we calculated the percentage difference between the 10th and 90th percentile of claims’ 

payment rates. We excluded claims for beneficiaries in demonstration programs, claims where 

Medicaid was not the only payer, and claims that were adjusted. We performed a regression 

analysis to examine the extent to which variations in payments could be explained by differences in 

provider type, service setting, and patient age; and to determine the magnitude of variation 

associated with each factor. We selected these factors because previous studies by the Urban 

Institute found them to be present in fee schedules and they could be extracted from the claims 

data. To determine the extent to which Medicaid provider payment rates calculated from claims 

data confirmed rates reported in studies of states’ fee schedules, we calculated median payment 

rates from the claims data and compared these to fee schedule rates reported by AAP and the 

Urban Institute. To help ensure comparability, we restricted the claims in this part of our analysis to 

those most comparable to the fees used by the AAP and the Urban Institute studies. Generally, this 

involved restricting those claims to the service provided by a physician or dentist, in an office, and 

to a child. To the extent that the rates calculated from claims data differed from the reported rates 

based on fee schedule data, we used information obtained from state Medicaid program websites 

to explore potential reasons for any differences we observed. A more detailed discussion of our 

scope and methodology can be found in enclosure 1. Tables detailing the results of our analysis 

can be found in enclosure 2.

We conducted our work from September 2012 to January 2014 in accordance with all sections of 

GAO’s Quality Assurance Framework that are relevant to our objectives. The framework requires 

that we plan and perform the engagement to obtain sufficient and appropriate evidence to meet our 

stated objectives and to discuss any limitations in our work. We believe that the information and 

data obtained, and the analysis conducted, provide a reasonable basis for any findings and 

conclusions in this product.

Results in Brief

Among the states and services we examined, our analysis indicated that all states varied Medicaid 

payments for at least some services based on the circumstances under which the services were 

provided. However, the states differed in the number of services for which they varied payments, in 

the factors that accounted for variation, and in the magnitude of the variation. Many of the states 

varied payment rates by at least one of the factors we were able to explore in detail: provider type, 

service setting, and/or patient age. Some states also varied their payment rates for other reasons, 

such as by geographic region or by physician specialty. We also found that most of the median 

Medicaid payment rates calculated from claims data generally confirmed payment rates published 

in studies of fee schedules; however, some of the published fee schedule rates were rarely used in 

practice as the selected circumstance—such as the service being provided by a physician—rarely 

occurred. As a result, our findings demonstrate that Medicaid FFS claims data is a valid source of 

information on Medicaid provider payments, which have the potential to provide a more complete 

representation of provider payments than do fee schedules, as claims data can capture both the 

distribution and frequency of actual payments to providers.

 3

The nine states selected were Alabama, Iowa, Illinois, Louisiana, Montana, Nebraska, Pennsylvania, South Carolina, and

Texas.
Page 3 GAO-14-56R Medicaid Payment Rates

All States Varied Medicaid Provider Payment Rates for Some Services, but Reasons for Variation 

Differed

Among the states and services we examined, all states varied Medicaid provider payment rates for 

at least some services. However, the states differed in the number of services for which they varied 

payments, in the factors that accounted for variation, and in the magnitude of the variation. As 

shown in table 1, among the 9 states we examined, the most variation in payments was in Texas, 

where payments varied by more than 10 percent for 22 services, and by more than 50 percent for 

7 services. The least variation in payments was in Nebraska and Pennsylvania, where payment 

rates varied by more than 10 percent for just 4 services. (See table 5 in enclosure 2 for more detail 

on the variation in provider payments for each state and service.)

Table 1: Number of Medicaid Services for Which States Varied Provider Payment Rates and Magnitude of Variation, by State, 

Calendar Year 2010

States included in analysis Alabama Iowa Illinois Louisiana Montana Nebraska Pennsylvania

South 

Carolina Texas

Number of services for which 

data were available 32 34 31 31 31 32 30 32 31

Number of services with variation 

greater than 10 percent 15 21 10 22 16 4 4 8 22

Number of services with variation 

greater than 25 percent 13 11 7 10 14 3 3 5 11

Number of services with variation 

greater than 50 percent 7 5 7 1 3 1 2 0 7

Source: GAO analysis of Centers for Medicare & Medicaid Services data.

Note: We selected 35 professional medical services from among those included in recent studies by the American Academy of Pediatrics 

and the Urban Institute. We chose these services to represent a range of professional medical service categories—including evaluation 

and management, imaging, laboratory, and maternal health. We determined the level of variation in payment by comparing the 90th and 

10th

States also differed in the factors that contribute to payment rate variation and in the proportion of 

payment variation associated with each factor. In most states, some of the variation in payment 

rates could be explained by differences in provider type, service setting, and patient age. In 3 of the 

states with substantial variation in provider payment rates—Louisiana, Montana, and Texas—much 

of the variation could be accounted for by these 3 factors. For example, in Montana, more than half 

of the variation in payment rates could be explained by these factors in 56 percent of services. In 

3 other states—Alabama, Iowa, and Illinois—very little of the variation in payment rates could be 

attributed to provider type, setting, and patient age. Less than 25 percent of the variation in 

payments was due to these factors in over 80 percent of services in these states. (See table 6 in 

enclosure 2 for more detail on the variation in Medicaid provider payment accounted for by provider 

type, service setting, and patient age for each service and state.) An examination of states’ fee 

schedules indicated that states also varied their payment rates for reasons beyond the 3 factors we 

explored. For example, for certain services, Alabama varied payment rates by geographic region, 

Montana varied rates for certain services by provider specialty, and Illinois varied rates depending 

on whether providers were enrolled in a special primary health care program.

percentiles of payment rates for all Medicaid claims for each service.

Furthermore, even among states that varied payments on the same factor, the states differed in the 

magnitude of the variation associated with that factor. For example, non-physicians were paid about 

21 percent less than physicians on average in Louisiana, while they were paid about 8 percent less 

in Texas, according to our analysis of claims data. In Montana, services provided in a facility 

(inpatient hospital, outpatient hospital, or emergency department) were reimbursed about 
Page 4 GAO-14-56R Medicaid Payment Rates

32 percent less than those provided in an office, while in Louisiana, there was no difference in 

payment by setting. Payment rates for services provided to adults were generally less than for 

those provided to children, but the difference varied among states. On average, services provided 

to adults were reimbursed 12 percent less in Louisiana, 3 percent less in Montana, and 9 percent 

less in Texas.

Medicaid Provider Payment Rates Calculated from Claims Data Generally Confirmed Rates 

Reported in Fee Schedule Studies, but Some Rates Were Rarely Used

The median Medicaid payment rates calculated from claims data generally confirmed payment 

rates published in studies of fee schedules, once we restricted claims to those most comparable to

the fees used by the studies.4

Where the median payment rate calculated from claims data differed from that published in the fee 

schedule studies, we were generally able to identify the source of the difference. For example, for 

the two emergency department (ED) services shown in table 2, the AAP study reported fee 

schedule rates in Texas of $46 and $62. However, the current Texas fee schedule specifies that if 

the enrollee’s diagnosis is nonemergency, Medicaid pays just 60 percent of the standard rate for 

these services. In that case, the rates for these services would be $28 and $37, which essentially 

equaled the median payment rates we calculated from the claims data. Thus, while the rate 

reported by AAP was consistent with the current Texas fee schedule, it did not reflect the number of 

ED visits in Texas that were paid at a reduced rate.

Specifically, of the 257 state and service combinations for which we 

had both claims and fee schedule data, 148 (58 percent) had median claims payment rates that 

were within 1 percent of the published fee schedule rates, and another 71 (28 percent) had median 

payments within 10 percent. (See table 7 in enclosure 2 for the median payment rate calculated 

from claims data for each service and state. See table 8 in enclosure 2 for a comparison of the 

rates calculated in claims with those reported in studies of fee schedules for each service and 

state.)

 4

Generally, this involved restricting the claims to the service provided by a physician or dentist, in an office, and to a child. 

(See table 4 in enclosure 1.)
Page 5 GAO-14-56R Medicaid Payment Rates

Table 2: Percentage Difference between Medicaid Provider Payment Rates Calculated from Claims Data and Rates Reported in 

Fee Schedule Studies, Selected Services and States, Calendar Year 2010

Percent difference between median claims payments and fee schedule rates

Selected Medicaid Services Alabama Iowa Illinois Louisiana Montana Nebraska Pennsylvania

South 

Carolina Texas

Initial hospitalization, per 

day, moderate complexity 15 - -1 13 -1 -1 2 -1 -

Subsequent hospitalization, 

per day, low complexity 20 - -2 16 - -2 - -2 -

Subsequent hospitalization, 

per day, moderate complexity - -1 - 12 1 -1 - -1 -1

Emergency department visit,

problem focused - 1 -1 18 -1 -1 1 -2 -69

Emergency department visit,

expanded - 1 -1 15 3 -1 - -1 -66

Source: GAO analysis of Centers for Medicare & Medicaid Services, American Academy of Pediatrics (AAP), and Urban Institute data.

Notes: A positive value indicates that the median payment rate calculated from Medicaid claims data is higher than the payment rate 

presented in recent AAP and Urban Institute studies using fee schedule data. To help ensure comparability, we restricted the claims in 

this part of our analysis to those most comparable to the fees used by the AAP and the Urban Institute studies. Generally, this involved 

restricting those claims to the service provided by a physician or dentist, in an office, and to a child. (See table 4 in enclosure 1. See 

table 8 in enclosure 2 for data from all services included in our analysis.)

The difference between claims data and fee schedule rates for some services in Alabama may 

reflect differing rates for rural and non-rural areas, a factor we did not account for in our analysis. 

For example, for the initial hospitalization service, we calculated a median claims payment of $95, 

which is the rate shown in the current state fee schedule for rural areas. The AAP and Urban 

Institute both reported a payment rate of $81 for this same service, which is the rate shown in 

Alabama’s fee schedule for non-rural areas. In the case of Louisiana, the difference between the 

median payment rates we calculated for children and the fee schedule rates reported by the AAP 

and Urban Institute appear to be due to the AAP having reported payment rates for adults for at 

least some services. The median payment rates that we calculated were consistent with the 

Louisiana fee schedule rates for children.5

We also examined how frequently the fee schedule rates reported in the AAP and Urban Institute 

studies were actually used to pay claims, and found that some were rarely used in practice. For 

example, the fee schedule rate reported by the Urban Institute in Texas for a CAT scan of the head 

or brain was $169.6 However, that rate applied to fewer than 10 percent of actual payments for the 

service, and was less than half the $357 overall median payment for the service we calculated from 

claims data.7

 5

According to the Louisiana Medicaid fee schedule in effect from August 1, 2010 through November 30, 2010.

In Montana, the fee schedule rate for a 40 to 50 minute individual, face-to-face 

psychotherapy session reported by AAP was $90. However, this rate applied to fewer than 

10 percent of the payments Montana made for the service, and it was nearly twice the overall 

median payment of $57 calculated from claims data. This discrepancy is likely due to AAP reporting 

the enhanced rate for psychiatrists over other physicians, while the much lower rate we found in the 

claims more closely corresponded to the rate paid to non-physician mental health providers.

6

The fee schedule rate reported by the Urban Institute was for services provided by a physician in an office.

7

The overall median payment for a CAT scan of the head or brain in Texas—not limited to a specific provider type, setting, 

or beneficiary age—was $357 in 2010 as calculated from claims data. The median payment we calculated from claims 

data for services limited to those provided by a non-physician, in an office, and to a child was $174.
Page 6 GAO-14-56R Medicaid Payment Rates

Agency Comments

The Department of Health and Human Services reviewed a draft of this report and provided 

technical comments, which we incorporated as appropriate.

– – – – –

For further information regarding this report, please contact me at (202) 512-7114 or 

YocomC@gao.gov. Copies of this report will be sent to the Secretary of Health and Human 

Services. In addition, the report will be available at no charge on the GAO website at 

http://www.gao.gov. Contact points for our Offices of Congressional Relations and Public 

Affairs may be found on the last page of this report. Major contributors to this report were 

Christine Brudevold, Assistant Director; Eric Anderson; Alison Binkowski; William Black; 

Greg Dybalski; Nancy Fasciano; Sandra George; Drew Long; and Hemi Tewarson.

Carolyn L. Yocom

Director, Health Care
Page 7 GAO-14-56R Medicaid Payment Rates

List of Congressional Committees

The Honorable Max Baucus

Chairman

The Honorable Orrin G. Hatch

Ranking Member

Committee on Finance

United States Senate

The Honorable Thomas Carper

Chairman

The Honorable Tom Coburn

Ranking Member

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Fred Upton

Chairman

The Honorable Henry Waxman

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Darrell E. Issa

Chairman

The Honorable Elijah Cummings

Ranking Member

Committee on Oversight and Government Reform

House of Representatives
Enclosure I

Page 8 GAO-14-56R Medicaid Payment Rates

Scope and Methodology

We prepared this report under the authority of the Comptroller General to conduct work on GAO’s 

initiative to assist Congress with its oversight responsibilities for the Medicaid program. In this report, 

we provide information on: (1) the extent to which state Medicaid programs vary the rates paid to 

providers for a given service and the basis for the variation; and (2) the extent to which Medicaid 

provider payment rates calculated from claims data confirm rates reported in studies of states’ fee 

schedules.

To conduct this work, we examined 2010 Medicaid fee-for-service (FFS) claims data for selected 

professional services and states. States submit Medicaid eligibility and claims data to the Centers for 

Medicare & Medicaid Services’ (CMS) Medicaid Statistical Information System (MSIS) on a quarterly 

basis. We used 2010 claims data from the Medicaid Analytic Extract to calculate median payment 

rates for 35 services in 9 states. The Medicaid Analytic Extract (MAX) data is a set of person-level 

data files on Medicaid eligibility, service utilization, and payment, which are based on data extracted 

from the Medicaid Statistical Information System. The MAX data are created specifically to support 

research and policy analysis, and combine initial claims and adjustments for a given service into final 

action claims arrayed on a calendar year basis.1 The payments in the MAX data represent the actual 

amounts Medicaid paid to providers and do not include beneficiary cost-sharing.2

We selected 35 professional services from among those included in the studies by the American 

Academy of Pediatrics (AAP) and the Urban Institute. Both studies relied on surveys of states’ fee 

schedules. As part of its effort to monitor the impact of the Medicaid program on pediatrics, AAP has 

periodically conducted a survey of states to collect Medicaid fee schedule data. The most recent 

published survey requested payment rates effective July 1, 2010, and reported data from the 46 

states that responded. For those states, the study reported on payment rates for 235 pediatric 

services and, with a few exceptions, reported the rate applicable when the service was provided by a 

physician, in an office, and to a child. Since 1993, the Urban Institute has conducted its study of 

Medicaid fee schedules approximately every 5 years. The authors shared unpublished results from 

their 2010 survey for our analysis. The Urban Institute study collected physician fee schedule data on 

32 services for all 49 states that have a FFS program. The survey focused on rates for services 

provided by a physician in an office; if a state otherwise had multiple payment rates for the same 

service—for example, different rates for urban and rural areas—the authors reported the average of 

those rates. Together, the AAP and Urban Institute studies included 255 services—235 in the AAP 

study and 32 in the Urban study, with 12 appearing in both. From those 255 services, we selected 35 

services across a range of professional service categories—including evaluation and management, 

imaging, laboratory, and maternal health. (See table 3.)

To assess the 

reliability of the claims data we used in our analyses, we reviewed related documentation, interviewed 

knowledgeable officials from CMS and its contractor responsible for processing these data, and 

compared our results to published sources.

 1

We restricted our analysis to the MAX other claims file, which contains claims for physician and other outpatient services. 

We excluded three additional MAX claims files: inpatient hospital, long-term care, and prescription drugs.

2

In some cases, states may require beneficiaries to pay deductibles, copayments and similar charges for certain Medicaid 

services. Federal law generally restricts such cost-sharing to nominal amounts; however, states may impose additional costsharing on certain populations and for certain services.
Enclosure I

Page 9 GAO-14-56R Medicaid Payment Rates

Table 3: Selected Services and Service Categories

Appears in

Service Category AAP Urban Service

Office visits X Established patient, problem-focused

X X Established patient, low complexity

X X Established patient, moderate complexity

X X New patient, low complexity

X X New patient, moderate complexity

Preventive services X One immunization administration

X Established patient, under 1 year

X Established patient, 1 through 4 years

Cardiovascular X Routine venipuncture

X X Echocardiography, with image documentation

X Doppler echocardiograph

Emergency department/critical care X Emergency department visit, problem focused

X X Emergency department visit, expanded

X Emergency department visit, detailed

Inpatient/non-emergency department X X Initial hospitalization, per day, moderate complexity

X Subsequent hospitalization, per day, low complexity

X X Subsequent hospitalization, per day, moderate complexity

X Subsequent hospitalization, per day, high complexity

Eye, ear, nose and throat X Ophthalmological services, new patient

X Ophthalmological services, established patient

X Screening test, hearing evaluation

Maternal/newborn care X Vaginal delivery only, no postpartum care

X Vaginal delivery and postpartum care

X Cesarean delivery and no postpartum care

Mental/behavioral health X Individual psychotherapy, 20-30 minutes face-to-face

X Individual psychotherapy, 45-50 minutes face-to-face

X Pharmacologic management

Pathology/laboratory X Urinalysis, non-auto., without microscopy

X Rapid Streptococcus screen

Radiology X Frontal chest x-ray

X X-ray, chest, two views

X CAT scan, head or brain

Dental X Periodic exam

X Prophylaxis, child

X Sealant, per tooth

Source: GAO analysis of Centers for Medicare & Medicaid Services, American Academy of Pediatrics (AAP), and Urban Institute data.

Note: We selected 35 professional services from among those included in the studies by the AAP and the Urban Institute. Together, the 

AAP and Urban Institute studies included 255 services—235 in the AAP study and 32 in the Urban Institute study, with 12 appearing in 

both.
Enclosure I

Page 10 GAO-14-56R Medicaid Payment Rates

We selected 9 states from among the 26 states with available 2010 MAX data as of October 2012. 

We chose states that represented different regions of the country and that served a relatively large 

proportion of their Medicaid population through FFS arrangements rather than through managed 

care. We first eliminated 2 states that were not included in the AAP or Urban Institute studies–

Georgia and Tennessee. We then grouped states by Census region such that our sample 

represented a sizeable proportion of the total Medicaid enrollment. When selecting states within each 

region, we gave preference to states with higher enrollment. However, we also sought to ensure that 

the sample included states with relatively small as well as large enrollment. Given that our study 

focused on FFS rates, we gave preference to states that had higher percentages of enrollees—

particularly higher percentages of children—in FFS arrangements, as opposed to comprehensive 

risk-based managed care arrangements. The 9 states we selected based on these criteria were 

Alabama, Illinois, Iowa, Louisiana, Montana, Nebraska, Pennsylvania, South Carolina, and Texas.

To determine the extent to which state Medicaid programs varied the rate they paid for a given 

service, we calculated the median payment amount and the percentage difference between the 10th

and 90th percentile of claims payment rates (P90/P10) for each service.3 To further explore this 

variation and examine the extent to which variations in payment could be explained by differences in 

provider type, service setting, and patient age, we performed a regression analysis.4 Selected 

regression results are presented in table 6 in enclosure 2.5

To determine the extent to which Medicaid provider payment rates calculated from claims data

confirmed rates reported in existing studies of states’ fee schedules, we calculated median payment 

rates from the claims data and compared these to fee schedule rates reported by the AAP and the 

Urban Institute. To help ensure comparability, we restricted the claims in this part of our analysis to 

those most comparable to the fees used by the AAP and the Urban Institute studies. Generally, this 

involved restricting those claims to the service provided by a physician or dentist, in an office, and to 

a child. For 8 services for which we had fee schedule data from both the AAP and Urban Institute 

studies, we used the AAP rate in our analysis. See table 4 for fee schedule rates and claims 

restrictions used in the comparative analysis. To the extent that claims payments differed from fee 

schedule data, we used fee schedule information obtained from state Medicaid program websites to 

explore potential reasons for any differences we observed.

 3

To calculate payment rates from the claims for our selected services and states, we first identified claims in the MAX file 

that represented (1) FFS payment; (2) full, final payment; and (3) payment for services provided to the general Medicaid 

population. We developed criteria to exclude claims that did not meet these requirements. We excluded claims for 

beneficiaries in demonstration programs, claims where Medicaid was not the only payer, and claims that were adjusted. 

4

Specifically, our dependent variable was the log of the Medicaid payment rate and our independent variables were binary 

indicator variables for (i) whether the service was provided by a physician or dentist (reference category), non-physician, or 

other health professional; (ii) whether the service was provided in an office(reference category), facility (inpatient hospital, 

outpatient hospital, or emergency department), or other setting; and (iii) whether the service was provided to a child 

(reference category defined as less than 18 years old and basis of eligibility was child), adult (defined as greater than 

21 years old and basis of eligibility was adult), or a patient of other/unknown age. By specifying a log-linear model, the 

resulting regression coefficients represent the percentage difference in mean payment rates associated with changing the 

specified independent variable.

5

We only presented results where (i) there was sufficient variation in the dependent variable (which we defined as 

P90/P10 >= 1.1); (ii) there was sufficient variation in the independent variable (which we defined as N>=30 for each value 

of the indicator variable); and (iii) the r2 of the regression was at least 0.25.
Enclosure I

Page 11 GAO-14-56R Medicaid Payment Rates

Table 4: Fee Schedule Rates and Claims Restrictions Used in Comparative Analysis

Service Fee schedule rate used Restrictions applied to claims

Established patient, problem-focused

a

AAP P-O-C

Established patient, low complexity AAP P-O-C

Established patient, moderate complexity AAP P-O-C

New patient, low complexity AAP P-O-C

New patient, moderate complexity AAP P-O-C

One immunization administration AAP P-O-C

Established patient, under 1 year AAP P-O-C

Established patient, 1 through 4 years AAP P-O-C

Routine venipuncture AAP P-O-C

Echocardiography, with image documentation AAP P-O-C

Doppler echocardiograph AAP P-O-C

Emergency department visit, problem focused AAP P-F-C

Emergency department visit, expanded AAP P-F-C

Emergency department visit, detailed AAP P-F-C

Initial hospitalization, per day, moderate complexity AAP P-F-C

Subsequent hospitalization, per day, low complexity AAP P-F-C

Subsequent hospitalization, per day, moderate complexity AAP P-F-C

Subsequent hospitalization, per day, high complexity AAP P-F-C

Ophthalmological services, new patient Urban P-O-C

Ophthalmological services, established patient Urban P-O-C

Screening test, hearing evaluation AAP P-O-C

Vaginal delivery only, no postpartum care Urban P-F-A

Vaginal delivery and postpartum care Urban P-F-A

Cesarean delivery and no postpartum care Urban P-F-A

Individual psychotherapy, 20-30 minutes face-to-face AAP P-O-C

Individual. psychotherapy, 45-50 minutes face-to-face AAP P-O-C

Pharmacologic management AAP P-O-C

Urinalysis, non-auto., without microscopy AAP NP-O-C

Rapid Streptococcus screen AAP NP-O-C

Frontal chest x-ray AAP NP-O-C

X-ray, chest, two views Urban NP-O-C

CAT scan, head or brain Urban NP-O-C

Periodic exam (dental) AAP P-O-C

Prophylaxis, child (dental) AAP P-O-C

Sealant, per tooth (dental) AAP P-O-C

Source: GAO analysis of Centers for Medicare & Medicaid Services, American Academy of Pediatrics (AAP), and Urban Institute data.

Note: For 8 services for which we had fee schedule data from both the AAP and Urban Institute studies, we used the AAP rate in our 

analysis.

a

P = physician/dentist; NP = non-physician; F = facility (inpatient hospital, outpatient hospital, or emergency department); O = office; 

A = adult; C = child.
Enclosure II

Page 12 GAO-14-56R Medicaid Payment Rates

This enclosure includes the following detailed data tables:

Table 5-A: Distribution of Medicaid Provider Payment Rates, by State and Service, 

Calendar Year 2010 (Alabama, Iowa, and Illinois)

Table 5-B: Distribution of Medicaid Provider Payment Rates, by State and Service, 

Calendar Year 2010 (Louisiana, Montana, and Nebraska)

Table 5-C: Distribution of Medicaid Provider Payment Rates, by State and Service, 

Calendar Year 2010 (Pennsylvania, South Carolina, and Texas)

Table 6: Percent Difference in Medicaid Provider Payment Rates Accounted for by 

Provider Type, Service Setting, and Patient Age, Selected States and Services, Calendar 

Year 2010

Table 7: Median Medicaid Provider Payment Rates Calculated from Claims, Selected 

States and Services, Calendar Year 2010

Table 8: Percentage Difference between Medicaid Provider Payment Rates Published in 

Previous Studies Based on Fee Schedules and Rates Calculated from Claims Data, 

Selected States and Services, Calendar Year 2010
Enclosure II

Page 13 GAO-14-56R Medicaid Payment Rates

Table 5-A: Distribution of Medicaid Provider Payment Rates, by State and Service, Calendar Year 2010 (Alabama, Iowa, and 

Illinois)

Alabama Iowa Illinois

Service Median P10 P90 P90/10 Median P10 P90 P90/10 Median P10 P90 P90/10

Routine venipuncture — — — — 3 3 6 2.00 — — — —

Vaginal delivery only, no 

postpartum care 1,041 950 1,250 1.32 759 759 759 1.00 924 924 924 1.00

Vaginal delivery and 

postpartum care 1,161 1,000 1,300 1.30 836 836 836 1.00 924 924 924 1.00

Cesarean delivery and no 

postpartum care 1,041 950 1,250 1.32 893 889 893 1.00 1,070 1,070 1,070 1.00

CAT scan, head or brain 158 158 273 1.73 199 196 199 1.02 247 247 247 1.00

Frontal chest x-ray 20 20 34 1.70 25 13 25 1.92 17 17 17 1.00

X-ray, chest, two views 23 23 23 1.00 32 27 32 1.19 22 22 22 1.00

Urinalysis, non-auto., without 

microscopy 3 3 3 1.00 4 3 8 2.67 3 3 3 1.00

Rapid Streptococcus screen 14 14 14 1.00 17 13 17 1.31 16 16 16 1.00

One immunization 

administration 5 5 5 1.00 7 4 17 4.25 — — — —

Individual psychotherapy, 

20-30 minutes face-to-face 47 47 47 1.00 33 33 55 1.67 68 28 68 2.43

Individual psychotherapy, 

45-50 minutes face-to-face 71 71 71 1.00 86 77 87 1.13 68 68 102 1.50

Pharmacologic management 37 37 37 1.00 43 43 46 1.07 22 22 68 3.09

Ophthalmological services, 

new patient 84 75 84 1.12 96 65 96 1.48 46 37 46 1.24

Ophthalmological services, 

established patient 62 61 62 1.02 70 67 70 1.04 44 44 44 1.00

Screening test, hearing 

evaluation 16 10 16 1.60 14 14 14 1.00 20 15 32 2.13

Echocardiography, with image 

documentation 134 125 134 1.07 — — — — 91 91 91 1.00

Doppler echocardiograph 71 71 106 1.49 88 78 116 1.49 20 20 40 2.00

New patient, low complexity 78 77 79 1.03 81 77 81 1.05 42 40 44 1.10

New patient, moderate 

complexity 111 110 113 1.03 117 114 117 1.03 68 64 70 1.09

Established patient, problemfocused 31 30 38 1.27 31 28 31 1.11 26 22 26 1.18

Established patient, low 

complexity 42 34 43 1.26 43 36 43 1.19 47 28 47 1.68

Established patient, moderate 

complexity 67 61 68 1.11 66 58 66 1.14 71 41 73 1.78

Initial hospitalization, per day, 

moderate complexity 95 81 145 1.79 106 98 106 1.08 51 51 51 1.00

Subsequent hospitalization, 

per day, low complexity 24 24 44 1.83 33 31 37 1.19 16 16 16 1.00

Subsequent hospitalization, 

per day, moderate complexity 40 40 72 1.80 51 50 55 1.10 25 25 25 1.00
Enclosure II

Page 14 GAO-14-56R Medicaid Payment Rates

Alabama Iowa Illinois

Service Median P10 P90 P90/10 Median P10 P90 P90/10 Median P10 P90 P90/10

Subsequent hospitalization, 

per day, high complexity 102 57 102 1.79 72 69 76 1.10 35 35 35 1.00

Emergency department visit, 

problem focused 21 21 21 1.00 29 29 29 1.00 24 24 24 1.00

Emergency department visit, 

expanded 42 42 42 1.00 59 59 59 1.00 32 32 32 1.00

Emergency department visit, 

detailed 66 66 66 1.00 90 90 90 1.00 44 44 44 1.00

Established patient, under 

1 year — — — — 72 51 72 1.41 — — — —

Established patient, 1 through 

4 years — — — — 75 56 79 1.41 — — — —

Periodic exam (dental) 18 18 18 1.00 18 16 19 1.19 28 28 28 1.00

Prophylaxis, child (dental) 28 28 28 1.00 23 21 26 1.24 41 41 41 1.00

Sealant, per tooth (dental) 26 26 26 1.00 20 17 23 1.35 36 36 36 1.00

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Note: For each service, the table displays the median payment, payment rates at the 10th percentile (P10) and 90th percentile (P90), 

and the ratio of the 90th to the 10th percentiles (P90/P10).
Enclosure II

Page 15 GAO-14-56R Medicaid Payment Rates

Table 5-B: Distribution of Medicaid Provider Payment Rates, by State and Service, Calendar Year 2010 (Louisiana, Montana, and 

Nebraska)

Louisiana Montana Nebraska

Service Median P10 P90 P90/P10 Median P10 P90 P90/P10 Median P10 P90 P90/P10

Routine venipuncture — — — — 3 3 3 1.00 4 4 4 1.00

Vaginal delivery only, 

no postpartum care 581 522 653 1.25 831 831 866 1.04 810 806 810 1.00

Vaginal delivery and 

postpartum care 671 671 755 1.13 1,002 970 1,002 1.03 960 960 965 1.01

Cesarean delivery and 

no postpartum care 687 687 687 1.00 986 354 1,025 2.90 1,119 1,113 1,119 1.01

CAT scan, head or brain 160 153 167 1.09 — — — — 197 197 198 1.01

Frontal chest x-ray 18 14 19 1.36 — — — — 23 23 23 1.00

X-ray, chest, two views 23 20 25 1.25 — — — — 30 30 31 1.03

Urinalysis, non-auto., 

without microscopy 3 2 3 1.50 4 4 4 1.00 4 4 4 1.00

Rapid Streptococcus 

screen 14 12 15 1.25 17 17 17 1.00 17 17 17 1.00

One immunization 

administration 15 15 15 1.00 16 14 16 1.14 6 6 6 1.00

Individual psychotherapy, 

20-30 minutes face-to-face 50 50 50 1.00 41 41 41 1.00 35 35 35 1.00

Individual psychotherapy, 

45-50 minutes face-to-face 76 76 76 1.00 57 57 58 1.02 64 64 64 1.00

Pharmacologic 

management 48 46 48 1.04 71 52 72 1.38 42 37 42 1.14

Ophthalmological services, 

new patient 107 85 107 1.26 96 65 112 1.72 35 35 55 1.57

Ophthalmological services, 

established patient 87 59 87 1.47 89 67 92 1.37 35 35 47 1.34

Screening test, hearing 

evaluation 7 6 7 1.17 10 10 10 1.00 13 13 13 1.00

Echocardiography, with 

image documentation 120 120 128 1.07 — — — — 224 224 224 1.00

Doppler echocardiograph 63 53 63 1.19 65 65 75 1.15 106 106 106 1.00

New patient, low complexity 77 62 78 1.26 94 72 97 1.35 69 69 70 1.01

New patient, moderate 

complexity 118 101 121 1.20 147 118 152 1.29 104 102 104 1.02

Established patient, 

problem-focused 31 25 31 1.24 38 24 38 1.58 30 30 30 1.00

Established patient, low 

complexity 52 42 52 1.24 63 45 65 1.44 45 45 45 1.00

Established patient, 

moderate complexity 76 63 79 1.25 95 67 98 1.46 68 68 68 1.00

Initial hospitalization, per day, 

moderate complexity 103 89 107 1.20 130 130 131 1.01 83 83 84 1.01

Subsequent hospitalization, 

per day, low complexity 27 27 32 1.19 49 39 49 1.26 29 28 29 1.04

Subsequent hospitalization, 

per day, moderate complexity 49 49 58 1.18 71 70 88 1.26 45 45 46 1.02
Enclosure II

Page 16 GAO-14-56R Medicaid Payment Rates

Louisiana Montana Nebraska

Service Median P10 P90 P90/P10 Median P10 P90 P90/P10 Median P10 P90 P90/P10

Subsequent hospitalization, 

per day, high complexity 79 70 83 1.19 102 101 127 1.26 76 52 76 1.46

Emergency department (ED) 

visit, problem focused 35 29 35 1.21 41 41 42 1.02 34 34 34 1.00

ED visit, expanded 53 43 54 1.26 65 63 65 1.03 51 51 51 1.00

ED visit, detailed 84 84 101 1.20 119 119 122 1.03 60 60 61 1.02

Established patient, under 

1 year 61 61 64 1.05 76 52 77 1.48 — — — —

Established patient, 

1 through 4 years 68 68 71 1.04 85 61 86 1.41 — — — —

Periodic exam (dental) — — — — 23 23 23 1.00 17 17 17 1.00

Prophylaxis, child (dental) — — — — 33 33 33 1.00 21 21 22 1.05

Sealant, per tooth (dental) — — — — 26 26 26 1.00 — — — —

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Note: For each service, the table displays the median payment, payment rates at the 10th percentile (P10) and 90th percentile (P90), 

and the ratio of the 90th to the 10th percentiles (P90/P10).
Enclosure II

Page 17 GAO-14-56R Medicaid Payment Rates

Table 5-C: Distribution of Medicaid Provider Payment Rates, by State and Service, Calendar Year 2010 (Pennsylvania, South 

Carolina, and Texas)

Pennsylvania South Carolina Texas

Service Median P10 P90 P90/P10 Median P10 P90 P90/P10 Median P10 P90 P90/P10

Routine venipuncture — — — — 2 2 2 1.00 — — — —

Vaginal delivery only, 

no postpartum care 1,200 1,200 1,200 1.00 1,200 1,200 1,200 1.00 567 561 668 1.19

Vaginal delivery and 

postpartum care 1,200 1,200 1,200 1.00 — — — — 689 656 746 1.14

Cesarean delivery and 

no postpartum care 1,200 1,200 1,200 1.00 1,200 1,200 1,200 1.00 674 667 700 1.05

CAT scan, head or brain 78 78 117 1.50 168 168 168 1.00 357 175 553 3.16

Frontal chest x-ray 12 11 19 1.73 18 18 18 1.00 27 19 69 3.63

X-ray, chest, two views 15 14 25 1.79 24 24 24 1.00 28 25 96 3.84

Urinalysis, non-auto., 

without microscopy 4 4 4 1.00 3 3 3 1.00 4 3 4 1.33

Rapid Streptococcus screen 6 6 6 1.00 15 15 15 1.00 16 16 17 1.06

One immunization 

administration — — — — 13 13 13 1.00 8 8 8 1.00

Individual psychotherapy, 

20-30 minutes face-to-face — — — — 59 59 59 1.00 35 35 36 1.03

Individual psychotherapy, 

45-50 minutes face-to-face — — — — 77 77 77 1.00 70 61 81 1.33

Pharmacologic management — — — — 45 37 45 1.22 45 42 46 1.10

Ophthalmological services, 

new patient 56 48 59 1.23 103 74 103 1.39 100 88 105 1.19

Ophthalmological services, 

established patient 45 43 45 1.05 84 75 84 1.12 86 65 86 1.32

Screening test, hearing 

evaluation 8 8 8 1.00 8 8 8 1.00 16 16 16 1.00

Echocardiography, with 

image documentation 139 137 140 1.02 136 136 136 1.00 122 115 161 1.40

Doppler echocardiograph 65 62 65 1.05 70 60 70 1.17 53 53 82 1.55

New patient, low complexity 54 51 54 1.06 74 59 74 1.25 61 55 62 1.13

New patient, moderate 

complexity 87 87 90 1.03 115 113 115 1.02 83 74 90 1.22

Established patient, 

problem-focused 26 24 26 1.08 29 27 29 1.07 25 23 25 1.09

Established patient, low 

complexity 35 33 35 1.06 50 40 50 1.25 38 34 38 1.12

Established patient, 

moderate complexity 51 51 54 1.06 75 73 75 1.03 52 47 53 1.13

Initial hospitalization, per 

day, moderate complexity 28 28 30 1.07 101 101 101 1.00 105 95 105 1.11

Subsequent hospitalization, 

per day, low complexity 16 16 17 1.06 30 30 30 1.00 35 31 35 1.13

Subsequent hospitalization, 

per day, moderate complexity 16 16 17 1.06 55 55 77 1.40 50 45 50 1.11
Enclosure II

Page 18 GAO-14-56R Medicaid Payment Rates

Pennsylvania South Carolina Texas

Service Median P10 P90 P90/P10 Median P10 P90 P90/P10 Median P10 P90 P90/P10

Subsequent hospitalization, 

per day, high complexity 17 16 17 1.06 79 79 110 1.39 67 61 68 1.11

Emergency department visit, 

problem focused 27 25 27 1.08 32 32 32 1.00 27 25 46 1.84

Emergency department visit, 

expanded 35 35 35 1.00 50 50 50 1.00 37 34 62 1.82

Emergency department visit, 

detailed 50 48 50 1.04 94 94 94 1.00 81 49 90 1.84

Established patient, under 1 

year 20 20 20 1.00 — — — — — — — —

Established patient, 

1 through 4 years 20 20 20 1.00 — — — — — — — —

Periodic exam (dental) 20 19 20 1.05 23 23 23 1.00 29 29 29 1.00

Prophylaxis, child (dental) 30 30 30 1.00 29 29 29 1.00 38 37 38 1.03

Sealant, per tooth (dental) 25 25 25 1.00 24 24 24 1.00 —- — — —

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Note: For each service, the table displays the median payment, payment rates at the 10th percentile (P10) and 90th percentile (P90), 

and the ratio of the 90th to the 10th percentiles (P90/P10).
Enclosure II

Page 19 GAO-14-56R Medicaid Payment Rates

Table 6: Percent Difference in Medicaid Provider Payment Rates Accounted for by Provider Type, Service Setting, and Patient 

Age, Selected States and Services, Calendar Year 2010

Percent difference in payment ratea

Services State

Non-physician 

vs. physician

Facility 

vs. office

Adult 

vs. child

Percent of payment

rate variation

due to 3 factors

Mean 

payment rate

Established patient, low complexity

b

Alabama — 0.30 -0.01 0.46 41.84

Established patient, moderate 

complexity

Alabama — 0.08 -0.01 0.27 67.09

Established patient, low complexity Iowa -0.15 0.02 -0.05 0.52 41.78

Established patient, moderate 

complexity

Iowa -0.13 0.01 -0.03 0.30 64.16

Ind. psychotherapy, 20-30 minutes 

face-to-face

Illinois — -0.01 0.01 0.79 64.85

Pharmacologic management Illinois — 0.26 0.05 0.64 30.50

Vaginal delivery and postpartum 

care

Louisiana -0.22 0.01 -0.03 0.37 678.37

Frontal chest x-ray Louisiana — — 0.05 0.67 18.20

Doppler echocardiograph Louisiana — — -0.19 0.28 63.19

New patient, low complexity Louisiana -0.18 -0.01 -0.12 0.41 71.93

New patient, moderate complexity Louisiana -0.19 -0.02 -0.12 0.47 110.60

Established patient, problemfocusedLouisiana -0.19 0.00 -0.16 0.69 29.04

Established patient, low complexity Louisiana -0.20 0.00 -0.17 0.61 48.56

Established patient, moderate 

complexity

Louisiana -0.22 -0.02 -0.10 0.48 73.25

Initial hospitalization, per day, 

moderate complexity

Louisiana -0.19 0.02 -0.14 0.56 98.97

Subsequent hospitalization, per day, 

low complexity

Louisiana -0.20 0.00 -0.14 0.58 28.83

Subsequent hospitalization, per day, 

moderate complexity

Louisiana -0.22 0.00 -0.12 0.52 52.31

Subsequent hospitalization, per day, 

high complexity

Louisiana -0.23 -0.01 -0.12 0.33 75.28

Emergency department visit, 

problem focused

Louisiana -0.22 — -0.17 0.63 32.74

Emergency department visit, 

expanded

Louisiana -0.21 — -0.16 0.69 49.33

Emergency department visit, 

detailed

Louisiana -0.22 — -0.14 0.67 89.31

Pharmacologic management Montana -0.26 -0.19 0.00 0.83 65.86

New patient, low complexity Montana -0.04 -0.27 -0.03 0.88 89.00

New patient, moderate complexity Montana -0.06 -0.24 -0.02 0.81 140.69

Established patient, problemfocusedMontana -0.03 -0.45 -0.03 0.95 34.14
Enclosure II

Page 20 GAO-14-56R Medicaid Payment Rates

Percent difference in payment ratea

Services State

Non-physician 

vs. physician

Facility 

vs. office

Adult 

vs. child

Percent of payment

rate variation

due to 3 factors

Mean 

payment rate

Established patient, low complexity

b

Montana -0.01 -0.32 -0.03 0.82 57.72

Established patient, moderate 

complexity

Montana -0.04 -0.33 -0.03 0.77 89.59

Subsequent hospitalization, per day, 

low complexity

Montana -0.11 — -0.09 0.55 44.62

Subsequent hospitalization, per day, 

moderate complexity

Montana -0.07 — -0.02 0.32 73.58

Subsequent hospitalization, per day, 

high complexity

Montana -0.05 — -0.02 0.32 108.31

Established patient, under 1 year Montana -0.04 -0.39 — 0.73 67.45

Established patient, 1 through 

4 years

Montana -0.03 -0.34 — 0.64 76.17

CAT scan, head or brain Pennsylvania — -0.36 -0.02 0.44 85.03

Frontal chest x-ray Pennsylvania — -0.42 -0.01 0.44 12.84

X-ray, chest, two views Pennsylvania — -0.44 -0.04 0.72 18.57

Pharmacologic management South Carolina — -0.18 0.00 0.76 43.86

Doppler echocardiograph South Carolina — — -0.13 0.30 68.49

New patient, low complexity South Carolina -0.11 -0.28 -0.02 0.79 71.84

Established patient, low complexity South Carolina -0.14 -0.29 -0.02 0.76 48.76

Subsequent hospitalization, per day, 

high complexity

South Carolina -0.23 — -0.19 0.38 88.71

CAT scan, head or brain Texas — 0.79 0.00 0.31 377.67

Frontal chest x-ray Texas — 0.98 -0.05 0.75 38.55

X-ray, chest, two views Texas — 1.03 -0.05 0.78 48.59

New patient, low complexity Texas -0.06 -0.40 -0.11 0.76 58.46

New patient, moderate complexity Texas -0.08 -0.41 -0.11 0.79 82.23

Established patient, low complexity Texas -0.07 -0.38 -0.11 0.75 36.79

Established patient, moderate 

complexity

Texas -0.08 -0.38 -0.11 0.74 50.36

Initial hospitalization, per day, 

moderate complexity

Texas -0.08 — -0.10 0.55 102.54

Subsequent hospitalization, 

per day, low complexity

Texas -0.09 — -0.10 0.87 33.70

Subsequent hospitalization, per day, 

moderate complexity

Texas -0.08 — -0.11 0.84 48.38
Enclosure II

Page 21 GAO-14-56R Medicaid Payment Rates

Percent difference in payment ratea

Services State

Non-physician 

vs. physician

Facility 

vs. office

Adult 

vs. child

Percent of payment

rate variation

due to 3 factors

Mean 

payment rate

Subsequent hospitalization, per day, 

high complexity

b

Texas -0.09 — -0.10 0.85 65.71

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Note: Table includes only those services with payment variation of at least 10 percent between the 90th and 10th percentiles and

where at least 25 percent of the variation could be explained by the 3 factors in our regression analysis—provider type 

(physician/dentist vs. non-physician), service setting (facility vs. office), and patient age (adult vs. child). Percentage difference in 

payment rate is shown as missing when there was insufficient variation in that factor (N < 30 for one or more values of the factor); 

services where all factors had insufficient variation were not included in the table. Facilities included inpatient hospital, outpatient 

hospital, and emergency department.

a

The percent difference in payments are relative to the second value listed in the column. For example, a percentage difference of 

0.30 in the facility vs. office column implies that the payment rate when the service was provided in a facility was, on average, 

30 percent more than the rate when the service was performed in an office.

b

The mean payment is the rate paid for services provided by a physician or dentist, in an office, and to a child.
Enclosure II

Page 22 GAO-14-56R Medicaid Payment Rates

Table 7: Median Medicaid Provider Payment Rates Calculated from Claims, Selected States and Services, Calendar Year 2010

Service Alabama Iowa Illinois Louisiana Montana Nebraska Pennsylvania

South 

Carolina Texas

Routine venipuncture — 3 — — 3 4 — 2 —

Vaginal delivery, no 

postpartum care 1041 759 924 581 831 810 1200 1200 567

Vaginal delivery and 

postpartum care 1161 836 924 671 1002 960 1200 — 663

Cesarean delivery, 

no postpartum care 1041 893 1070 687 986 1119 1200 1200 674

CAT scan, head or brain 158 199 247 160 — 197 117 168 174

Frontal chest x-ray 20 25 17 18 — — 19 18 19

X-ray, chest, two views 23 32 22 23 — 30 25 24 25

Urinalysis, non-auto., 

without microscopy 3 4 3 3 — — 4 3 4

Rapid Streptococcus screen 14 17 16 14 — — 6 15 16

One immunization 

administration 5 7 — — 16 6 — 13 8

Individual psychotherapy, 

20-30 min 47 — 28 — — 35 — 55 50

Individual psychotherapy, 

45-50 min 71 — 48 — — 64 — 77 70

Pharmacologic 

management 37 — 22 48 71 42 — 45 45

Ophthalmological services, 

new patient 84 96 46 107 130 45 59 103 104

Ophthalmological services, 

established patient 62 70 44 87 106 47 45 84 86

Screening test, hearing 

evaluation 16 14 — — 10 13 8 8 16

Echocardiography 134 — 91 144 — — 140 — 122

Doppler echocardiograph 71 88 20 63 65 106 65 70 53

New patient, low complexity 78 81 44 77 97 69 54 74 62

New patient, moderate 

complexity 111 117 70 118 152 104 90 115 90

Established patient, 

problem-focused 31 31 26 31 38 30 26 29 25

Established patient, low 

complexity 42 43 47 52 63 45 35 50 38

Established patient, 

moderate complexity 67 66 73 76 98 68 54 75 53

Initial hospitalization per 

day, moderate complexity 95 106 51 103 130 83 30 101 105

Subsequent hospitalization, 

per day, low complexity 30 33 16 32 39 28 17 30 35

Subsequent hospitalization, 

per day, moderate 

complexity 40 51 25 55 71 45 17 55 50

Subsequent hospitalization, 

per day, high complexity 102 72 35 79 102 76 17 110 68
Enclosure II

Page 23 GAO-14-56R Medicaid Payment Rates

Service Alabama Iowa Illinois Louisiana Montana Nebraska Pennsylvania

South 

Carolina Texas

Emergency department 

visit, problem focused 21 29 24 35 41 34 27 32 27

Emergency department 

visit, expanded 42 59 32 53 65 51 35 50 37

Emergency department 

visit, detailed 66 90 44 97 122 60 50 94 89

Established patient, under 

1 year — 72 — 61 77 — 20 — —

Established patient, 

1 through 4 years — 76 — 68 85 — 20 — —

Periodic exam (dental) 18 18 28 — — 17 20 23 29

Prophylaxis, child (dental) 28 23 41 — — 21 30 29 38

Sealant, per tooth (dental) 26 20 36 — — — 25 24 —

Source: GAO analysis of Centers for Medicare & Medicaid Services’ data.

Notes: (1) To help ensure comparability, we restricted the claims in this part of our analysis to those most comparable to the fees 

used by the American Academy of Pediatrics and the Urban Institute studies. Generally, this involved restricting those claims to the 

service provided by a physician or dentist, in an office, and to a child. (See table 4 in enclosure 1.) (2) Missing data for a particular 

state and service could be due to (a) the states’ Medicaid fee-for-service program never providing the service in the selected 

circumstances, or (b) limitations of the claims data that make it difficult to definitively identify all services that were provided in the 

selected circumstances.
Enclosure II

Page 24 GAO-14-56R Medicaid Payment Rates

Table 8: Percentage Difference between Medicaid Provider Payment Rates Published in Previous Studies Based on Fee 

Schedules and Rates Calculated from Claims Data, Selected States and Services, Calendar Year 2010

Percentage Difference

Services AL IA IL LA MT NE PA SC TX

Routine venipuncture — -5% — — 0% -10% — -29% —

Vaginal delivery only, no postpartum care 9% 0% 0% -12% 0% 0% 0% 0% -2%

Vaginal delivery and postpartum care 1% 0% 0% -12% 3% 0% -35% -2%

Cesarean delivery and no postpartum care 9% 0% 0% -6% 0% 0% 0% 0% -2%

CAT scan, head or brain 37% 0% 0% 7% — 0% 0% 0% 3%

Frontal chest x-ray 0% 65% 0% 2% — — 0% -4% 1%

X-ray, chest, two views 40% 2% 2% 0% — -2% 0% -3% 2%

Urinalysis, non-auto., without microscopy 0% 10% 13% 4% — — 11% -7% 12%

Rapid Streptococcus screen 0% 40% 2% -6% — — -5% 0% -3%

One immunization administration 0% 28% — — 3% 3% — 0% 0%

Individual psychotherapy, 

20-30 minutes face-to-face 0% — 2% — — — — — -1%

Individual psychotherapy, 

45-50 minutes face-to-face 0% — 1% — — — — — 0%

Pharmacologic management 0% — -2% — 20% — — — 1%

Ophthalmological services, new patient 0% 0% -1% 8% -1% -22% 0% 0% 1%

Ophthalmological services, established patient 0% 0% -1% 8% -2% -1% -1% 0% 2%

Screening test, hearing evaluation 69% 0% — — 2% -2% 0% 0% 2%

Echocardiography, with image 

documentation 0% — 0% 17% — — 0% — 0%

Doppler echocardiograph 0% 74% -99% 16% 1% 0% 0% 14% -1%

New patient, low complexity 0% 1% 1% 16% 0% -1% 0% 0% 1%

New patient, moderate complexity 0% 0% 0% 14% 0% 0% 0% 0% 0%

Established patient, problem-focused 0% 0% 1% 16% -1% 1% 0% -3% 0%

Established patient, low complexity 0% 0% 1% 16% -4% 0% 0% 0% 1%

Established patient, moderate complexity 0% 0% 0% 14% 0% 0% -1% 0% 0%

Initial hospitalization, per day, moderate complexity 15% 0% -1% 13% -1% -1% 2% -1% 0%

Subsequent hospitalization, per day, low complexity 20% 0% -2% 16% 0% -2% 0% -2% 0%

Subsequent hospitalization, per day, 

moderate complexity 0% -1% 0% 12% 1% -1% 0% -1% -1%

Subsequent hospitalization, per day, high complexity 44% 0% 0% 12% 1% 0% 0% 28% 0%

Emergency department visit, problem focused 0% 1% -1% 18% -1% -1% 1% -2% -69%

Emergency department visit, expanded 0% 1% -1% 15% 3% -1% 0% -1% -66%

Emergency department visit, detailed 0% 0% 0% 14% 3% -1% 0% -1% -1%

Established patient, under 1 year — 0% — -4% 1% — 0% — —

Established patient, 1 through 4 years — -4% — -5% 0% — 0% — —

Periodic exam (dental) 0% 10% 0% — — 0% 0% -2% -2%
Enclosure II

Page 25 GAO-14-56R Medicaid Payment Rates

Percentage Difference

Services AL IA IL LA MT NE PA SC TX

Prophylaxis, child (dental) 0% -6% 0% — — -5% 0% -3% 1%

Sealant, per tooth (dental) 0% -1% 0% — — — 0% 0% —

Source: GAO analysis of Centers for Medicare & Medicaid Services, American Academy of Pediatrics (AAP), and Urban Institute data.

Note: A positive value indicates that the median payment rate calculated from Medicaid claims data is higher than the payment rate 

presented in recent AAP and Urban Institute studies using fee schedule data. To help ensure comparability, we restricted the claims 

in this part of our analysis to those most comparable to the fees used by the AAP and the Urban Institute studies. Generally, this 

involved restricting those claims to the service provided by a physician or dentist, in an office, and to a child. (See table 4 in 

enclosure 1.)

(291051)
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