(018) Regional and Expansion Status Variation in Medicaid Reimbursement for Common ENT Procedures

Introduction: This study examines differences in Medicaid reimbursement for five common Otolaryngology procedures across expansion status and geographic region. The goal is to describe these patterns and highlight implications for patient access and long-term practice stability.

Methods: A cross-sectional analysis was conducted using 2025 state Medicaid fee schedules from all states and the District of Columbia for the following procedures: nasal endoscopy, flexible laryngoscopy, tympanostomy, planned tracheostomy, tonsillectomy >= 12 years old, and tonsillectomy < 12 years old. Reimbursement rates were adjusted for poverty, cost-of-living indices, and relative value units (RVUs). States were grouped by CDC region and expansion status. Statistical analysis included Welch’s ANOVA, Mann-Whitney U, and post-hoc tests (p < 0.05).

Results: The Midwest showed the lowest mean reimbursement overall, with lower rates than the South for Nasal Endoscopy (p=0.046) and Planned Tracheostomy (p=0.010), and lower than the West for Flexible Laryngoscopy (p=0.046), Planned Tracheostomy (p=0.013), Tonsillectomy >= 12 (p=0.028), and Tonsillectomy < 12 (p=0.020). Expansion states consistently reimbursed higher for all CPT codes, and after RVU adjustment, regional and expansion differences were no longer observed.

Conclusions: Reimbursement for common ENT procedures differs by region, with lower rates in the Midwest. Adjusting for RVUs eliminates these differences, suggesting variation comes from state conversion factors. Medicaid expansion states had improved reimbursement, but not per-RVU payment. Sustaining ENT care within Medicaid populations requires balancing a growing patient demand with long-term practice sustainability. Equitable reimbursement is an important consideration for ENT providers across regions to address imbalances and ensure access for Medicaid patients.