Wiki Fee schedule/Charge amount

[YesicaRuedas]

Hello All,

It was brought to our attention that providers must have a single fee schedule across the board for all payers (MC,HMO, COMMERCIAL etc. must be billed the same rate for the same servie)- under the "fair claims act". Can someone at your office please verify if that information is correct?

Thank you,
Yesica Ruedas

 

[csperoni]

1) This is a user forum. We are all simply other AAPC members, and can provide our opinions and/or resources. You should not take anything said on a user forum as legal advice.
2) Regardless of whether or not it is legal, it is a REALLY, REALLY, REALLY bad idea to have multiple fee schedules. I do know there are specific regulations for government carriers. For example, you charge 99213 to Medicare at $100 (allowed $90.82). For Cigna, $200 (allowed $180). For HealthFirst $80 (allowed $70). You cannot charge the government (Medicare) more than you charge others. Further more, lets say you think the patient has HealthFirst and later discover it's Cigna. You have already created a claim as $80 for the services provided but Cigna would have paid $180. Practices should set one fee schedule across the board, fully aware they will need to make significant contractual adjustments. Most practices do it at a percentage of the Medicare fee schedule, so it is based on RVUs. Set it a bit above your highest payor's fee schedule.
3) Legality can vary from state to state. It is possible it is legal in my state, but not legal in yours.

So, even IF you can charge different fee schedules, there are many reasons not to, and no reason you should.