Practice Management Alert

Question: My practice is getting reimbursed only about a third of our charges for colonoscopies. What can I do to make sure payment is correct?

Iowa Subscriber

 
Answer: First determine if the charge for colonoscopy is within the range of usual and customary fees for your geographic region. Medicare reimbursement for colonoscopy will have decreased about 34 percent from 1996 to 2002, and many HMOs pay a percentage of the Medicare allowable. So, if your doctor has a contract that pays 80 percent of Medicare, and Medicares allowable has gone down over the last few years, the reimbursement is less.
 
The American College of Gastroenterology has been addressing the decreasing reimbursement for colonoscopy, particularly with Medicare. You can easily compare the Medicare fee schedule against the explanation-of-benefit form to make sure you are getting paid the appropriate allowed amount from this payer. Check your managed-care contracts to see if they have provided you with their respective fee schedules. If not, write to each one and request the fee for the range of colonoscopies performed by your physician, i.e., the fee for diagnostic colonoscopy and the fee for colonoscopy with biopsy. Once you have the fee schedules, compare the EOB against the fee schedule to be certain you are receiving appropriate reimbursement.
 
The colonoscopy site of service affects payment. For example, if you do a colonoscopy in your office or in your groups surgical suite, you will receive about 22 percent more money than if you perform it in an outpatient-hospital setting. Insurance carriers dont have to pay a facility fee to the hospital when you perform the service in your office or surgical suite. Also check whether your physicians are coding the services and using modifiers correctly.