Wiki Billing different prices for in-office vs OR procedures

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dleightydreby@insightbb.com

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Does anyone know if you can bill a higher fee for a procedure performed in the office versus the normal fee for a procedure performed in the OR for self-pay patients? Our self-pay patients are given discounts when they go to the OR for surgery. Occasionally, these procedures can be done in-office, under local anesthesia, therefore avoiding the costs of a surgery center. Can we forego those discounts if we do the procedure in office?
 
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Physicians will usually bill (and be paid) a higher fee for the same procedure performed in their office than what they'd bill and be paid for that same procedure if done in a facility. The reason is that in the OR, the hospital is responsible for their own costs and is going to bill a separate fee for the use of the facility, whereas in the office the physician is responsible for and needs to be compensated for the use of the office space, the supplies and equipment, staff time, etc.

For self-pay patients, the fee you charge is generally considered a contractual arrangement between the patient and the provider, so it's really up to the provider to what they feel is an appropriate charge. Your provider can decide to discount or not discount their fees as they see fit, though for compliance purposes it should be done in a fair and equitable manner that does not give undue preference to one particular class of patients over another.
 
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This is a practice management, compliance and revenue topic. The CFO, Revenue Cycle Director, Compliance Director and/or another executive level person should be discussing this with providers. There can be compliance implications even when talking about self pay patients. There can also be physician pay implications depending on how providers are paid in the pratice by RVUs or salary (among other things). Thomas gives good advice above. If you look at the RVUs for facility versus office based procedures you will see differences as stated above due to the breakdown by work, practice expense, and malpractice.


In my opinion, you want self pay fees to be equivalent to an average of what a person covered by insurance would pay in co-pay, coinsurance and deductibles. However, you would expect procedures performed in your own office to be a higher cost because the practice is assuming all of the overhead rather than "sharing" it with the facility. Think of the fact that if you performed the procedure in a facility the patient would likely get multiple bills, provider, anesthesia, facility, etc. If in office it's all in one.
 
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