Wiki Medicare PPO

[aenorris35@gmail.com]

I am confused as to how we should be billing Medicare PPO and HMO. I work for a chiropractic office and we are non-par providers with Medicare. When the Dr. does NOT feel it is a Medicare covered service we bill with the appropriate modifiers to Medicare with the adjusted Medicare allowed amounts. My question is do we bill HMO and PPO with regular fee amounts, not the Medicare allowed amounts with modifiers?

 

[vanessamoldovan]

I am confused as to how we should be billing Medicare PPO and HMO. I work for a chiropractic office and we are non-par providers with Medicare. When the Dr. does NOT feel it is a Medicare covered service we bill with the appropriate modifiers to Medicare with the adjusted Medicare allowed amounts. My question is do we bill HMO and PPO with regular fee amounts, not the Medicare allowed amounts with modifiers?

Yes. You billed Medicare PPO/HMOs with the fee you would to other payers, such as UHC, Humana, etc. You would not necessarily bill them as you would bill Medicare. That being said, some of these payers do mirror Medicare policies, such as no consults, etc. Hope this helps.

 

[SharonCollachi]

Please don't bill with anything other than your regular fee schedule. When you take an adjustment up front, you are negatively influencing the "usual and customary" amounts in your area.

 

[sls314]

Is there a reason why you don't bill your regular charges to traditional Medicare? Most providers I've ever worked with have one fee schedule that gets billed to all payers.