Case Rate Vs. Fee for Service (FFS)

I realize this is a sore subject for many therapists and owners.

I’m not going to share my opinion about companies or practices and I don’t have any scientific data on outcomes for either model. This article will simply lay out the financial facts for Case Rates when compared to Fee for Service (FFS) in Pediatric Therapy under Florida Medicaid. This article is meant to be informative and to help providers evaluate their own reimbursement rates for contracting. I apologize upfront for all the charts and tables, but I can’t paint the picture any other way.

First, let’s talk about Third Party Administrators (TPAs). TPAs handle administrative processes for the FL Medicaid Payors. For instance, EviCore, and EQ Health handle Authorizations for WellCare and Straight Medicaid respectively. Similarly, ATA handles authorizations and payments for Sunshine, Simply, Humana, Molina and many others.

Most Medicaid Payors use the Fee for Service (FFS) payment model that pays a specific rate per “unit” of service. For example, 1 unit (15 mins) of Speech Therapy by an SLP pays $17.86. Other Payors use a “Case Rate” model that reimburses providers upfront for services that will be rendered. For example, Level 3 Case Rate will pay $360 every 60 days during a Plan of Care period without specifying the visit frequency.

This article will provide real numbers for what you can expect to be paid under each payment model over the course of a Plan of Care period (typically 6 months).

I’ve put together a chart and a table below which outline the reimbursement levels for a typical 6-month plan of care. While “Levels” don’t specify the amount of care a patient must receive, I added a frequency that generally lines up with each severity level. For example, if a patient receives a “Level 3” Case Rate, then I assumed that they would be getting 2 x 30-minute visits per week. Those numbers are different for every patient and every facility but it provides a basis for comparison.

The chart below shows a possible reimbursement comparison of three options.

Option 1. “Level 3” Case Rate Max reimbursement.
Option 2. Two visits per week at 30 minutes each by a full therapist at the FFS Rate.
Option 3. Two visits per week at 30 minutes each by a therapist assistant at the FFS Rate.