Wiki fee schedules

[Arlene]

Can anyone answer a question regarding fee schedules. In NC can you have 2 fee schedules-one for cosmetic procedures and one for ins/private pay procedures.

 

[jdrueppel]

This has always been a scary area for me. Most PPO contracts, as well as Medicare and Medicaid particiption agreements, contain language that provider will submit their "usual" charge. If you are running 2 fee schedules then how do you define your usual charge? You may have to defend your position. With the advances in medical and reconstructive procedures, more and more cosmetic procedures are becoming insurance covered procedures...examples: breast reconstruction following mastectomy or abdominoplasty following gastric bypass. So, if you are willing to accept $500 as payment in full from a patient that is paying cash but submit a claim to Medicaid for $1500 for the same procedure is this appropriate???? If you do elect to have 2 fee schedules I would make sure that your cosmetic fee schedule is NOT lower that ANY of your payers, including Medicare and Medicaid. I bill anesthesia and we have facilities that do cosmetic procedures. We bill using the same charge calculation methodology for all services (cosmetic or not) and what we will accept as payment in full is dependent on the plastics specific facility contract, if no facility contract exists then we expect payment based on our insurance (if covered procedure) contract or from the patient.

Julie, CPC

 

[Susan]

Can anyone answer a question regarding fee schedules. In NC can you have 2 fee schedules-one for cosmetic procedures and one for ins/private pay procedures.

I don't know the law within your state, but I find it easier to maintain one fee schedule regardless. My surgeon does cosmetic surgery and reconstructive surgery, we charge the same regardless of who is paying.