Wiki Multiple Fee Schedules

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abs1821

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My director and I are having a conversation about fee schedules and I have always been taught you can not bill multiple fee schedules. (I.E. I can not bill Cigna one rate for a CPT and bill BCBS a different rate for the same CPT). Anyone know if this is true or where I can find documentation to support this?

Thanks in advance!
 
This sounds like a contracting issue. As I understand it (I work with fee schedules and contracting) your contract outlines the parameters of your agreement. The rates reimbursed or "fee schedule" is an agreement. What you BILL them should not matter, as they are obligated to pay up to their allowable after applicable benefits are applied. I would reach out to your provider advocates for each insurance or atleast your most significant payers or network managers, etc. and get their view on it , asking if there are any provisions in your contract that address the issue specifically.
 
Yes, you should have ONE set fee that you charge on all claims that will cover all contracted rates. Ex: 99204, bill one fee to all patients, from Medicare to Medicaid and all the insurance plans. You send out that claim, then accept what your contracted allowable pays, and adjust off the difference as your contractual discount. You may have a portion that is the patient balance for copay or coinsurance or deductible. Your contract with each payer will state they will pay the lesser of the billed amount or the contracted allowable for that CPT code.
 
Implementing Fees for a practice

I am new and not so new to the forums, but I have been asked to help coming up with pricing for a behavioral health practice. This is new to me, so I have been reading a lot of different things. Most of the information I have read is stating that when pricing for a practice it is advisable to see what other offices are charging for their services (in your area), or based off CMS's fee schedule a rule of thumb that can be followed is to charge 1.5 - 2 x's the fee, or use your highest paying private carriers rate with a little tweaking? Can anyone tell me how you have tackled this process and how it has worked out?

I do understand as stated before in the post that we will only be paid our contracted rate from our payers no matter what our charges are, but I am more concerned about our self pay patients. Any information will help.

Thanks:confused:
 
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Clarification

MarcusM said:
Yes, you should have ONE set fee that you charge on all claims that will cover all contracted rates. Ex: 99204, bill one fee to all patients, from Medicare to Medicaid and all the insurance plans. You send out that claim, then accept what your contracted allowable pays, and adjust off the difference as your contractual discount. You may have a portion that is the patient balance for copay or coinsurance or deductible. Your contract with each payer will state they will pay the lesser of the billed amount or the contracted allowable for that CPT code.
Click to expand...

**Does this include self pay patients? My understanding is they have to becharged what we charge the ins companies but we can accept a a Time Of Service Discount. Correct?
 
You may offer a discount for self pay patients who pay at the time of service but that payment should not be lower than what Medicare allows for that CPT in your locale. For example, say Medicare allows $100 for CPT 99214 in your area. Your practice uses ,let's say, a 1.75 multiplier of the Medicare rates across the board so your billed charge for your 99214 is $175.00. BCBS may pay $125.43, Aetna pays $135.67, UHC pays $119.23. Your private pay self pay patient gets a bigger discount since you get paid at time of service, don't have to bill out a claim, and don't have to do any collections follow up. So you bill him the Medicare rate of $100.00.
 
Trying to get it right

So it is legal to use Medicare's FS allowable amount as a basis for calculating a new office's fee schedule? I am actually trying to calculate a new provider's fees and it would be so much easier if I could just say we always charge 15% more than what Medicare allows, but I wasn't sure if that was legal or not. Is it?

Is this formula still the go-to?
[(work RVU * work GPCI) + (transitioned non-facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor

Thanks in advance - this formula I have for calculating FS is really scary when I don't know what the RVU's are for this new office and asking the owner for all his financial info seems to be making him uneasy.
 
http://www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx

The CMS database already has everything calculated into the CPT code. Using the tool above, plug in your locale, the year, and the CPT code and it give you a facility fee and a non-facility fee. Since my last few contracts with Aetna, Cigna, BCBS and Humana (although we did not contract with Humana because they only offered 85% of the CMS fee schedule) and the workers compensation carriers, who all cite the CMS fee schedule in the contracts, then using this database for your practice is reasonable.
 
Thanks for the info! Yeah, I used the fee schedule calculator from that site for our area and codes we will be using, but I didn't know if you could mark up those prices or not. So, you're saying the contracts with health insurance carriers will tell us how much we can charge based on that CMS FS amount?
 
No, the contracts cannot tell you how much to charge as that would be price fixing. You have to pick the billed charge amount. The insurance contract usually states they will pay the lesser of the billed charges or the contractual rate which is usually based on the CMS fee schedule. I have seen billed charges by providers that are 1.2 times the CMS fee schedule for their location and I have seen billed charges that are 10 to 20 times the CMS fee schedule. I have also seen a $38,000.00+ billed charge for a CT scan of the lumbar spine that CMS allows about $241.09.
 
Thanks again for your help. I wanted to make sure it was allowable to make billed charges (for example) 10-20% higher than the CMS fee schedule amount without having documentation of why you charge that amount. For some reason I thought everyone had to calculate their own fee schedule based on overhead cost, malpractice cost, provider salary, etc. to substantiate their charges. But it makes me feel better that we can skip this calculation part and base our charges off of CMS's fee schedule amounts for our area. I greatly appreciate your help Mr. Murphy. So, if I understand correctly, a medical office can charge anything but insurance companies will only pay the lesser of the billed charge or what they stipulated in their contract. I feel much better now.

Best Regards,
Samantha A. Robbins, CPC
 
SymphonySamantha88 said:
Thanks again for your help. I wanted to make sure it was allowable to make billed charges (for example) 10-20% higher than the CMS fee schedule amount without having documentation of why you charge that amount. For some reason I thought everyone had to calculate their own fee schedule based on overhead cost, malpractice cost, provider salary, etc. to substantiate their charges. But it makes me feel better that we can skip this calculation part and base our charges off of CMS's fee schedule amounts for our area. I greatly appreciate your help Mr. Murphy. So, if I understand correctly, a medical office can charge anything but insurance companies will only pay the lesser of the billed charge or what they stipulated in their contract. I feel much better now.

Best Regards,
Samantha A. Robbins, CPC
Click to expand...

Yes, your last statement is correct. A good practice to get into, is to have all of your payers contracted amounts for the CPT codes you use, in one spreadsheet, that way you can compare them side by side. Pick a starting point for your office's set fee schedule...for example, 25% higher than the CMS fee schedule, and see if that is greater than the highest allowable of all of your payers. If it is, you are at a good point. If not, try 30%, 35%, etc.


HTH!!
 
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