Question Changing prices for CPT codes

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I work at a pediatric practice and just recently they have decided to change the charge amount for our CPT codes for Medicaid to the same amount we get reimbursed so we are not writing off much any more, my question is this what we should be doing, I was under the impression when I was in school that there had to some amount that was adjusted/written off?
 

trarut

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You can't have different fee schedules for different payers. You must have standardized rates with one fee schedule for all payers.

If you choose to reduce your fees to minimize the adjustments, tread carefully. Your contracted rates are typically not the same across all payers and you want to make sure you don't reduce your fees so much that you end up with codes where you are charging less than your contracted rate. If you have a code priced at $100.00 but your contracted rate with Plan A is $95.00 but Plan B reimburses $200.00 due to a carve out, you will only be paid $100.00 for that service by Plan B. The plan will not pay more than your billed rate out of the goodness of their heart.

Again, I would proceed with extreme caution.
 

csperoni

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Another vote for "Don't do it!" Your fee schedule should be the same across the board. You are always going to wind up with some amount of write off adjustment, and it's the same amount of work whether you write off $5 or $500.
Most offices either set their fees as a percentage of Medicare, or take their highest payor and add a percentage. I personally prefer option 1.
If your concern is more about trying to estimate what percentage of your A/R is truly expected, most systems will allow you to look over a time frame (say the last 12 months) and see the amount collected vs amount billed for each payor. I would have a spreadsheet of that percentage, and then just plug in the A/R for each of those payors to know what amount you expect to collect on your current A/R. Unless your contracts significantly change, that's a pretty good estimation.
 

sls314

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Thanks for all the feedback, what has happened is that the charge amount only for Medicaid and chip fee schedules have changed in our system.


This is such a terrible idea for a number of reasons.

1) It could affect your insurance contracts. If they find out that your billed charge is less for Medicaid, then you may be out of compliance with your contract and they could demand that you bill them the same charge amounts you're billing Medicaid. (You might think there's no way that could happen, but it can and does all the time.)

2) Who's going to be responsible for updating your charge amount every time the Medicaid fee schedule changes or gets updated? You're going to create a tremendous amount of administrative hassle. Either that or no one is going to update your charges.

If Medicaid increases reimbursement for something and you forget to change your charge, you'll end up missing out on money. You'll get paid the "lesser of" your charge instead of the increased reimbursement.


I cannot stress enough what a HUGE mistake your employer has made. I am 100% sure that this will end up hurting them financially down the road.
 

SharonCollachi

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^^^^ This. All of this. PLUS THIS:

You have now admitted in an open forum to committing Medicare fraud. You cannot bill Medicare MORE than you bill anyone else. You must bill Medicare your actual fee, and they pay either 80% of that or 80% of their fee schedule, whichever is lower.

Example:

You bill $500 for a 99215. Medicare allows $150 and pays $120; $30 is the coinsurance/copay to the patient.

You bill Medicaid $75 for 99215 because that's what Medicaid allows.

Your actual fee is $75, not $500. Now Medicare comes back and does an audit. 80% of $75 is $60, which is what Medicare should have paid, not $120. You now have to pay back $60 ($120-$60) for every 99215 you billed Medicare over the last five (?) years. Are you prepared to do that??? Now multiply that out by every CPT code you bill.

Don't think Medicare won't find out. They will.

This is bad. Very Bad. VERY, VERY BAD.
 

SharonCollachi

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Another thought: You said you're a pediatric practice. That doesn't necessarily mean you don't have Medicare patients (due to disability). Your commercial contracts likely have language similar to Medicare's in that you must bill them your actual fee.
 
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^^^^ This. All of this. PLUS THIS:

You have now admitted in an open forum to committing Medicare fraud. You cannot bill Medicare MORE than you bill anyone else. You must bill Medicare your actual fee, and they pay either 80% of that or 80% of their fee schedule, whichever is lower.

Example:

You bill $500 for a 99215. Medicare allows $150 and pays $120; $30 is the coinsurance/copay to the patient.

You bill Medicaid $75 for 99215 because that's what Medicaid allows.

Your actual fee is $75, not $500. Now Medicare comes back and does an audit. 80% of $75 is $60, which is what Medicare should have paid, not $120. You now have to pay back $60 ($120-$60) for every 99215 you billed Medicare over the last five (?) years. Are you prepared to do that??? Now multiply that out by every CPT code you bill.

Don't think Medicare won't find out. They will.

This is bad. Very Bad. VERY, VERY BAD.
I was just asking a question, I did admit to anything, I do not have the power to make these changes, we put our charge amount the same as the reimbursement amount is what I was told we are doing. Thanks for your feedback.
 
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Another thought: You said you're a pediatric practice. That doesn't necessarily mean you don't have Medicare patients (due to disability). Your commercial contracts likely have language similar to Medicare's in that you must bill them your actual fee.
We have Medicaid and Commercial patients primarily, so like our 99213 was priced at $90 and they changed it to $36.89 because that is the reimbursed amount from Medicaid. This was not my decision to do this I just wanted some feedback.
 

SharonCollachi

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We have Medicaid and Commercial patients primarily, so like our 99213 was priced at $90 and they changed it to $36.89 because that is the reimbursed amount from Medicaid. This was not my decision to do this I just wanted some feedback.
And your commercial contracts likely have a clause that you cannot bill them more than anyone else, so if Medicaid is being billed $36.89 and paying that, then you'll need to bill the same to your commercial contracts.
 

rachaelwilleford

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I was just asking a question, I did admit to anything, I do not have the power to make these changes, we put our charge amount the same as the reimbursement amount is what I was told we are doing. Thanks for your feedback.
Regardless of whether you made the change or not, you admitted that your practice is making this change. This isn't a berating of you because of something you did, the responders are trying to let you know so you can advise the powers that be that this isn't something that should be done and why.
 

thomas7331

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^^^^ This. All of this. PLUS THIS:

You have now admitted in an open forum to committing Medicare fraud. You cannot bill Medicare MORE than you bill anyone else. You must bill Medicare your actual fee, and they pay either 80% of that or 80% of their fee schedule, whichever is lower.

...

Don't think Medicare won't find out. They will.

This is bad. Very Bad. VERY, VERY BAD.
Take it easy here, the post admits no such thing. First of all, fraud requires intent - honest errors and misunderstandings can incur penalties, yes, but they do not rise to the level of being a crime of moral turpitude such as fraud.

I try to avoid accusing people of fraud on the forum - I feel it's just not appropriate given that no post can even come close to telling us all of the facts of a particular situation. The only people who have the authority to pass judgment and determine that someone has committed fraud are members of a jury that have heard the case in full. We are coders here, not jurors and not prosecutors.
 
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SharonCollachi

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Take it easy here, the post admits no such thing. First of all, fraud requires intent - honest errors and misunderstandings can incur penalties, yes, but they do not rise to the level of being a crime of moral turpitude such as fraud.

I try to avoid accusing people of fraud on the forum - I feel it's just not appropriate given that no post can even come close to telling us all of the facts of a particular situation. The only people who have the authority to pass judgment and determine that someone has committed fraud are members of a jury that have heard the case in full. We are coders here, not jurors and not prosecutors.
I get what you're saying, and I may have (most likely have been) too harsh.

HOWEVER (you knew this was coming, right?) ignorance of the "law" is no excuse and is not a defense. Don't bill any insurance or governmental plan without knowing what is required of you.
 
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