CMS sets national fee schedules for most drugs, DME, and physician services. However, there are numerous codes that are "Status C" or "Contractor Priced."
In my experience, for years, these locally prices often weren't published anywhere. Now, they frequently are published. Here are two examples.
- When the new Category I codes for the service provided by iRhythm were released in January 2021, they didn't have RVU values, meaning, they didn't have national prices.
- However, Wall Street analysts quickly tracked what their local prices were, because MACs (in this case Novitas) released them. And then you'll find investor calls where iRhythm management talk about how they're working with Novitas, how Novitas might revise the locally-set payment, and so on. (Entry point to the trade press, here.)
- Beginning this year, the MolDx program places its locally-set prices on a special website called "DEX" Diagnostics Exchange, here. Story here. (This followed some policy debates whether locally-set fee schedules product prices for Medicare providers were available under FOIA or were a business secret of a MAC).
- When the Heartflow code was new to the APC system, CMS initially priced it higher, $1500, based on some invoice data available at that time, prior to CMS access to hospital outpatient claims data.