Pediatric Coding Alert

In this era of mysteriously disappearing reimbursements from HMOs and PPOs, many pediatricians are asking themselves, Do insurance companies even care what your fee schedule is?

As Michael H. Gollub, MD, of Los Robles Pediatric Medical Group in Thousand Oaks, CA, puts it: Do insurance companies recognize individual practitioner charges for managed care patients, or do they have standardized reimbursement schedules by area, zip code, etc.? Gollub goes on to ask whether it even matters what the individual practitioner charge is. Does our charging profile have any practical significance any more with PPOs and HMOs?

Here are some keys to understanding managed care reimbursement and how it affects your fee schedule.

1. Most companies have standard reimbursements. The answer to both of Gollubs questions is it depends on the insurance company, says Charles A. Scott, MD, FAAP, a pediatrician in Medford, NJ and a regional CPT coding resource physician for the AAP. Most insurance companies, says Scott, do indeed have standard reimbursement schedules. Most list their reimbursements by CPT code, meaning that they will pay a certain amount for a certain code, regardless of what your fee schedule is.

2. Find out what plans pay. You can ask your plans for a list of fees, says Scott. Most will send you a sample fee list, with selected codes. The ones you are probably most interested in are 99213 and 99214, the level-three and level-four office visit codes. These are the most commonly used codes in pediatrics, says Scott. They will be your bread and butter. The key to getting proper reimbursement with managed care plans is to find out what they pay for these before you sign up. Remember, once youve signed up with a plan, youve basically agreed to accept their fee schedule.

3. You may have to write off some fees. This means that if an insurance company says it will pay $80 for a code, and your fee schedule is only $60 for that code, the company will gladly pay 100 percent of your fee, notes Scott. If, on the other hand, your fee schedule is $100 for that code, you are going to have to write off the other $20.

4. Dont tailor your billing practices to health plans. You shouldnt change your fee schedule based on what any one insurance company pays you, says Scott. In fact, you shouldnt alter your billing practices at all, he stresses. Its much better to just charge what you charge, and then make an adjustment when the EOB comes in, he says. Lets say Blue Cross will pay you $50 for a 99213, he says. If your standard fee for 99213 is $55, that means you have to write off the $5.

5. Do bill patients in other plans. If you dont participate in the plan the patient is in, you should bill the patient your standard feenot a lower feesays Scott. The parent then files a claim with his or her plan, and gets whatever the out-of-plan payment is. Scott doesnt like this system much. The money goes to them (the parents) and they keep it, he says succinctly. He is particularly annoyed when this happens with professional-courtesy visits: he has seen a child and charged nothing, and the other parent submits a claim to his or her insurance company and makes money on the deal. Theoretically, I should bill them [the parents], but I dont, he says.