Audit Cases Jul 21, 2025

Why the Variation of Physician Fees for the Same Medical Service?

Let us zero in on a service many physicians bill: CPT code 99291. Defined as “critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes,” the American Medical Association CPT codebook outlines specific rules and guidelines from the AMA’s CPT editorial panel regarding the use, reporting and billing of this code. It is key that physicians understand these guidelines to help ensure compliant coding and billing of critical care services. In this Audit Spotlight, we focus on the wide variation of physician fees for the same medical service.

AMA Principles of Medical Ethics

Along with the AMA CPT coding and billing guidelines referenced above, the AMA also offers ethics guidance for physicians found in Principles of Medical Ethics. The information in Chapter 11: Opinions on Financing & Delivery of Healthcare — 11.3.1 — Fees for Medical Services provides guidance regarding what physicians should and should not do.

Some of the “should do” includes charge reasonable fees based on the:

  • Kind of services
  • Difficulty or uniqueness of the services performed
  • Time required to perform the services
  • Skill required to perform the services
  • Experience of the physician
  • Quality of the physician’s performance

Some of the listed “should not do” include:

  • Recommend, provide or charge for unnecessary medical services
  • Charge excessive fees, contingent fees or fees solely to facilitate hospital admission
  • Charge a markup or commission
  • Profit on services rendered by other health care professionals

Claim Examples — A Wide Gap of Charges for CPT Code 99291

Examples of low, median and high physician charges specific to CPT code 99291 reported/billed on healthcare claims are listed below. Services are performed by different physicians in different cities in Florida (cities all within 100 miles of each other). Included is ClaimDOC’s pricing in each case scenario.

  • Lowest charge for CPT code 99291 — A physician located in Florida charged $305 for critical care services in 2025.
    • ClaimDOC pricing: $305.
  • Median charge for CPT code 99291 — A physician located in Florida charged $870 for critical care services in 2025.
    • ClaimDOC pricing: $262.01.
  • Highest charge for CPT code 99291 — A physician located in Florida charged $3,329 for critical care services in 2025.
    • ClaimDOC pricing: $267.25.

In the above examples, the exact same service (CPT code 99291) is performed by physicians. How is it possible that fees can vary so significantly? Disparities in the charges of healthcare services between physicians in the same specialty and same geographic location can impact a physician practice or group. It is important that physician fee schedules are structured in a methodical manner, be within applicable rules and regulations, and be justifiable to patients.

The Takeaway

Charges billed by physicians for services and procedures vary immensely. Whenever patients have the option, they should discuss expected fees with providers, use price-lookup tools, get clear estimates of charges prior to services from the provider, and consider alternatives of care and providers. Some providers are willing to negotiate the cost of their services or treatment.

The improper reporting of services, coding and billing errors, and egregious charges can complicate matters for members to understand their healthcare bills and payments, impact the collection of patient balances, build a reputation of providers charging high fees, create burdens for patients having no insurance, and a host of other issues.

When an individual receives a bill for healthcare services appearing questionable or inappropriate, an inquiry to the provider and/or health plan should be made to obtain an explanation of the services, corresponding charges and reimbursement.

Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Our high-quality and expert review of claims identifies and prevents improper medical claim payments and maximizes long-term cost savings opportunities. Employers turn to us seeking to establish fair reimbursement rates for their plans, allowing them to save money and provide richer benefits to their employees. A win-win for everyone.

Background

ClaimDOC’s comprehensive line-by-line review of claims uncovers errors that basic claim repricing and auto-adjudication do not catch, leading to greater savings for health plans and its plan members. Our audit team analyzes all types of healthcare claims for a variety of potential concerns including excessive usual and customary charges, duplication of claims, incorrect coding, unbundling of services, and many others. Our claims review is not intended to impact care decisions or medical practice.

Line-by-line claim auditing is included in DirectAccess+® — ClaimDOC’s modern reference-based pricing health plan solution that helps employers deliver successful and sustainable medical plans for employees.

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