Wiki Different Fee Schedules by payer

[Cher91600]

I just learned that my new office's Tricare contract has a clause that means we'll get either 100% of CMS or 65% of our fee which ever is less.

We have our billed fee schedule set at 120% of CMS, which means that Tricare is only paying us 65% because that is the lesser of the two.

Can I adjust my billed fee schedule for Tricare to be higher to match their fee schedule allowances (so we can get paid at least 100% of CMS), or does my billed amount have to stay the same for all payers?

Thank you,
Cher

 

[MarcusM]

Your fee schedule should be the same for all payers for multiple reasons, one of which is so you are not constantly adjusting your fees for each and every payer. In my opinion, your fee schedule should be high enough that all payers will pay the maximum allowable per your contracts. You can revise your fee schedule annually and a simple way is to use the CMS fee schedule for your locale and use a multiplier...just be consistent year to year for simplicity...maybe 2.5 times CMS, 3 times. Some articles indicate some providers charge up to ten times the Medicare rate, and I have seen some that are much higher than this. The provider will have a much higher A/R and more in the way of write offs, but you will make certain that you get paid the maximums on all payers.

 

[Cher91600]

Thank you for your input Marcus.

My EMR would allow me to set a different fee schedule for every carrier if I wanted, I wouldn't manually be adjusting anything.

Our fee schedule was set to ensure that our self pay patients are treated fairly while all insurance carriers max reimbursement was accounted for. The Tricare discount claus is not a problem I have had at other locations & was not brought to my attention until today.

Though I know it is possible to bill different fee schedules, and my EMR can arrange this automatically, what I would like to try to verify is the legality of doing so.

As a side note: AAPC's actually suggests fee schedules of 15-25% higher than CMS, (based on private contracts) as you need to be able to defend the validity of your fees during an audit. Unfortunately, in my 10 years of experience I have seen that billing 200% or more of CMS is often not considered reasonable, can actually trigger an audit, and is strongly discouraged by national experts. Even if an office is not audited, the financial reporting becomes useless and self pay patients are harmed by excessive costs.


Thanks again.