Practice Management Alert

Question: How can I find out what an insurance carrier's allowables are for certain procedures and services? Should I ask the insurance broker for our practice?
- 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. If this information remains unknown, carriers hope providers will bill them for less than the total allowable. You can avoid being kept in the dark by asking carriers to divulge their 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.

Whether or not you've already signed on, carriers are usually more likely to provide their fees for new patient, established patient, consult and inpatient codes. You may have a harder time wrangling surgical fees out of them.

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. (Stay tuned for more information next month on using an insurance broker.)

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 $1,000 for a service and the carrier pays you $1,000, you know that the carrier's allowable may above $1,000 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.

- The answers to the Reader Questions were provided and/or reviewed by Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J.