PJZ ASC Coder
New
We are a non-contracted multi-specialty ASC and our in house billing team spends a great deal of effort researching how a patient?s commercial policy is expected to allow before we accept a case. Up until recently we have been able to make an educated guess as to how the policy would allow for a given procedure by calling the insurance representative and asking if the policy allows payment based on reasonable and customary rates for the geographical area or an MCR based fee schedule. If the representative quotes that the policy allows per a reasonable and customary fee schedule then with some carriers we can go a step further and look up their policy online. If the policy states online that the "allowed amount for out of network providers is based on the geographical area for this or similar services" we then have always been paid per a reasonable and customary fee schedule. However, recently we have encountered a noticeable increase in misquotes from the insurance representatives and or hard copies of the patients policy that states allowance based on geographical area that have allowed at a rate based on the MCR fee schedule. Has anyone else encountered these difficulties? Does anyone have any suggestions on how to better verify the fee schedule on a policy? I would love to hear back from other out of network ASC's on this, sometimes I feel like we are on an island all by ourselves. Thank you in advance for your feedback!