Medicare Reimbursement

[janetsullivan]

Hello,

Provider bills CPT code 42815 (Status Indicator J1) TOB 131, line item billed charges $5285.00. Medicare allowed is $6311.06. Does Medicare reimburse the provider (hospital) greater than billed charges (the Medicare allowed)?

 

[ahrx13]

Most contracts I've seen will only reimburse for whatever is lower between the billed charges or the insurance allowed amount. If you are finding that your billed charges are below Medicare allowable amount (or any other insurance allowed amount), you may want to raise your charges.

 

[amyjph]

Was that the only thing on the claim? Because, I have seen on facility claims where one line item has the entire payment and the rest are zero but the total amount adds up to the contracted/allowed amount for the entire claim.
However, it could be your charge amount for the service is not high enough as suggested above, or something going on with contracts, or something else.
If it is a facility, the chargemaster or rev cycle uppers should be involved. Seems wild that this would not be something reviewed/updated if the charges are too low going out.