Wiki Appropriate reimbursement

[TJAlexander]

Reddit has a forum called AITA; for those of you that know, then you know. Anyway, I need to know if I'm just a horrible coder and biller. The surgeon I work for is an orthopedic surgeon who sometimes works on professional athletes that are hurt during play. The claims for the injuries are adjudicated by the leagues' worker's compensation insurance company. My surgeon insists that I bill these surgeries at upwards of $70K (this for a shoulder arthroscopy) and insists that I'm doing something wrong because we don't actually get paid that amount. We usually get paid according to the state WC Fee schedule or WCIC contractual rate. He tells me that he knows of other practices/surgeons that are able to collect this rate. Am I missing something?

I thought I was handling the situation correctly by billing the appropriate CPT code and diagnosis according to AMA conventions. The billed amount is usually 150 to 300% of Medicare/WC Fee Schedulee. Should I be doing something differently?

 

[sls314]

It sounds like your surgeon's expectations are unreasonable.

In most states, workers' compensation reimbursement is typically set by the state, and you can't balance bill the patient. In some states, you can negotiate a rate with a workers' compensation insurance company, but rarely will you see the company agree to pay significantly more than the state rate. Usually, it is a percentage of the state rate.

Just because the patients are professional athletes doesn't mean that he's going to be reimbursed exorbitant amounts. The same basic principles for any other type of workers' compensation patient would still apply.

I doubt that the other practices are truly getting reimbursed those rates from the work comp carrier unless there's some fraud or abuse involved.

 

[TJAlexander]

Thank you for that!

 

[JodiLynn]

I have a provider that does the same... " I know a someone who is getting paid for that" or "another practice gets more $ for that". I always respond with- please get me in contact with their biller so I can compare billing to see if I am missing something (I always act like I could be wrong). Never has this provider provided me a contact for her doctor friend biller. Never. I'm in peds, so not big dollar amounts like you you deal with. My suggestion is next time that is said ask for the same, in a very concerned manner- who did you hear that from specifically? Can you get me in contact with them? I want to ensure you are getting paid correctly for your time and services. I can almost 90% assure you your Doc will not be able to provide any of that... it will change to oh, well I heard...