Optometry Coding & Billing Alert

Question: How can I find out what an insurance carrier's allowables are for certain procedures and services?


North Carolina Subscriber

Answer: You should be able to find out a carrier's allowable fees for at least your top-25 codes simply by asking the insurance plan.

Unlike Medicare, which shares its entire fee schedule with providers, other insurance carriers can be secretive and protective about their allowable fees, hoping providers will bill them for less than the total allowable. You can avoid being kept in the dark by asking carriers to divulgetheir fees. Carriers usually never release their entire fee schedule, but if you ask them code-by-code, they will probably provide the information.

Start early: You should begin gathering fee information before you even sign on with a carrier. Tell the carrier you want its fees for at least your top-25 codes before you agree to participate.

Outside help: If you've tried talking to the payer directly and it won't share its fees, try asking your insurance broker for help. Sometimes a broker may have leverage that you don't when talking to payers.
 
Another way: If your practice participates with many payers, monitoring allowables by calling carriers for their fees can be an overwhelming task. You can also monitor allowable fees by paying attention to EOBs. If you charge $100 for a service and the carrier pays you $100, you know that the carrier's allowable may be more than $100 and you should be charging more.
 
Monitor your EOBs for a while and you'll start to see reimbursement patterns for certain codes with all your payers. This pattern will give you a good idea of the allowable without having to call and ask.