Wiki Billing question

[DeKoderPL27]

Practice where I work we have different providers what I mean by that : we have a sport medicine doc, internal medicine doc , APRNs, PAs, specialists (obgyn, surgery )When it comes to payments form for example anthem each provider would get different amount of payments for the same E/M codes . Does anyone know why??? does it have anything to do with their crudentials ?
thank you

 

[Pam Warren]

It depends on your contracts with your payers. CMS pays midlevels at 85% of the physician allowable, and some payers will reimburse specialists differently. Smaller practices typically get paid based on an established fee schedule, but if you are a bigger facility,or associated with a PHO, sometimes you can use their clout to negotiate a better reimbursement.

If your software supports it, you should load your fee schedule, by payer, and by provider so that you can verify when you post payments that you are being paid correctly based on that payer and depending on who provided the service. Payers make mistakes, and if you're not aware of your contracted allowance, you could be writing off dollars that you are entitled to.

 

[staylor64]

In multiple specialty group practices the group or the provider has a contract
with the PPO or HMO. So you need to look at your contracts. Also the PA will get paid at a lower % rate than the Physician.

That has been my experience with billing in our practice.


Shannnon