Wiki Rolling-up Multiple Surgery Charges

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akienitz

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We have seen providers rolling up charges for multiple, same-day surgical procedures under the primary code and then billing the other codes with $0 charges. They claim this is acceptable, however, then as a payer, we are unable to apply multiple surgery reductions (50%) to the secondary, etc. procedures because we don't know how much they provider charged.

Has anyone else come across this problem, and if so, how do you resolve the issue - denying the $0 lines back for charges???

Thanks
 
As a payer do you not just pay the contracted rate for the line item and if there is a charge that is less than the contracted rate you pay the lesser of the two or for a 0 charge you pay nothing?
 
Yes, we pay the contracted rate or billed charges, whichever is less. However, standard practice with multiple surgeries performed on the same day is to pay only the primary procedure (highest RVU value or charges, depending on the payer) at 100% and to only allow 50% of the contracted rate for subsequent procedures under multiple procedure coding.

Example -
Code A - charge/contractd rate = $2,100
Code B - charge/contracted rate = $1,500

Payers will allow 100% of Code A ($2,100) and only 50% of Code B ($750) for a total of $2,850.

If provider bills Code A at $3,600 ("rolling up" the charges) and Code B at $0, they will be overpaid by $750.
 
akieni said:
Yes, we pay the contracted rate or billed charges, whichever is less. However, standard practice with multiple surgeries performed on the same day is to pay only the primary procedure (highest RVU value or charges, depending on the payer) at 100% and to only allow 50% of the contracted rate for subsequent procedures under multiple procedure coding.

Example -
Code A - charge/contractd rate = $2,100
Code B - charge/contracted rate = $1,500

Payers will allow 100% of Code A ($2,100) and only 50% of Code B ($750) for a total of $2,850.

If provider bills Code A at $3,600 ("rolling up" the charges) and Code B at $0, they will be overpaid by $750.
Click to expand...

But if the contracted rate for Code A is $2,100, then what the provider charges is irrelevant. You will simply pay the contracted rate, the remainder is a write-off for the provider. And if they give a $0 charge for code B, which you would typically pay at 50%...50% of nothing is $0, which means the provider is missing out on possible reimbursement. Or is the contracted rate based on a percentage of the charge amount, instead of a set flat rate?

I definitely don't agree that the provider should be billing this way, it does seem unethical, I'm just trying to understand the reasoning in getting to "overpaid by $750". :confused:
 
mhstrauss said:
But if the contracted rate for Code A is $2,100, then what the provider charges is irrelevant. You will simply pay the contracted rate, the remainder is a write-off for the provider. And if they give a $0 charge for code B, which you would typically pay at 50%...50% of nothing is $0, which means the provider is missing out on possible reimbursement. Or is the contracted rate based on a percentage of the charge amount, instead of a set flat rate?

I definitely don't agree that the provider should be billing this way, it does seem unethical, I'm just trying to understand the reasoning in getting to "overpaid by $750". :confused:
Click to expand...

That's a very good point. No matter what we charge, we get the same amount per our contracted fee schedule.
 
By bundling, if the reimbursement is a percent of savings, they get overpaid. If it's a flat fee schedule, they are going to get underpaid.
 
I don't understand your reasoning. Since the provider is paid on the LESSER of the billed amount or the contracted fee, he could charge $10,000 for procedure A and he is still only going to get $2,100. However by billing 0 for procedure B he is cheating himself out of $750 the insurance company is not overpaying anything. The payment is not based on a percentage of savings it based on the billed charge of EACH separate procedure.
 
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