Wiki Confused about Billing-Need Help

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mhth727@gmail.com

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HI,

I have a few questions and hope someone here would be a great resource with some help! My first question is about contractual obligations/adjustments. Normally practices/providers have their charged/billed amount as above the medicare allowable. So say they bill 99214, $125 is their rate/charge. The insurance allowable is $62.50, pt has a $10 copay and the contractual obligation(adjusted/write off) would be $52.50. Is it legal for a provider/practice to bill their allowed amt as the charged amount so they don't have to take any write off/contractual obligations? So if the allowable for 99214 is $62.50 that would be their charged/billed amount to the insurance.

And secondily, has anyone worked with ABA therapy codes? I have a few questions in regards to coding and billing some codes and wanted some insight. So was looking for someone I could email and pick their brains on a few things.

Thank You!

Hopefully I wasn't too confusing! :)
 
Sorry, but I don't see how that would possibly work. You have different contractual agreements with different payers, so there are different allowed amounts depending upon the payer. Also, if you have someone that is self pay, you would be losing money because you would basically be giving them the discounted rate that you've negotiated with other payers. I've done billing for several different practices prior to being a coder, and I've never seen this done. I think you have to charge everyone the same, and then post the contractual adjustments based on the allowed amount as usual. I know it can be a pain, but it is part of the process.

No experience with ABA therapy, but hopefully someone else will be able to help you on that part.

Susan
 
It is ok to bill the contracted amount. It is helpful to have a fee schedule for your various payers - though admittedly this could be overwhelming if your practice bills a huge variety of codes, and has many different payers. It depends upon your billing software, but you may be able to enter the fee schedule for each company, and the system will apply it when you enter the charges (based off the insurance that has been entered into the patient’s record.) You also can have a private pay fee schedule for your practice.

Sorry, I don't have any advice for your ABA question.
 
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