Annual Updates to Commercial Physician and Outpatient Hospital Fee Schedules

Commercial products (including Tufts Health Freedom Plan)

October 30, 2020  

Effective January 1, 2021, Tufts Health Plan will update its Commercial physician and outpatient hospital fee schedules. Tufts Health Plan will continue to base fees on the CMS fee schedules adjusted to achieve the contracting level of compensation, unless otherwise stated in your provider contract.

Outpatient Hospitals

  • Consistent with prior years, compensation will be based on a combination of ancillary and surgical fee schedules.
  • Drug pricing will continue to be set in relation to CMS.

Physicians

  • Consistent with prior years, additional funding will continue to be directed toward the compensation of certain primary care services when provided by a PCP or PCP/SCP, as initially modeled by CMS.
  • Tufts Health Plan will allocate a higher proportion of funds compared with CMS to the following services: pathology codes, radiology codes, ED visits with emphasis on the lower-level codes and certain E&M codes when performed in an office setting.
  • Tufts Health Plan will continue to base vaccine and toxoid compensation on CMS Part B levels when these rates are at 95% of average wholesale price (AWP), as indicated on the CMS Part B drug quarterly notices. When a rate for a vaccine is not AWP-based, Tufts Health Plan will set the compensation at the wholesale acquisition cost (WAC). Compensation for vaccines and toxoids will continue to be updated on a quarterly basis.
  • As in prior years, pricing for oncology and non-oncology drugs will continue to be set in relation to CMS, or to AWP/WAC if no CMS pricing is available.
  • Tufts Health Plan will continue to compensate for consultations, diverging from CMS.

Note: These changes do not apply to Allied Health providers. Additional details on fee schedule changes and applicable 2021 fee schedules will be distributed to hospital and provider organization leadership. For more information, refer to the Noncovered/Nonreimbursable Services Payment Policy for a comprehensive list of all nonreimbursable procedures. Independent physicians who have questions about fee schedule changes should contact Tufts Health Plan’s Network Contracting Department at 888.880.8699, ext. 52169.