Personal Injury Insurance


Best answers
If a provider bills only PIP insurance and they provide post surgical home care visits (out of global and/or no global) what percentage of Medicare Fee Schedule would they charge? How would they calculate charge.

For example CPT code: 99435 has a MFS payment rate of 244.21 What would the provider set their charge at?

Thank you!
Providers can set their charge at whatever amount they feel is reasonable and/or appropriate. There's no requirement that it be any amount in particular or that it be based on Medicare. It's recommended that providers make sure that they are billing rates that are equal to or higher than the fees that they have contracted with all of their commercial payers so that no potential revenue is lost. The providers I've worked with have used 150-200% of Medicare because it accomplished this and also simplifies the process of setting rates for individual services.
Some PIP payors will also reimburse these services at the 80th percentile of Usual & Customary, in which case you would be expected to charge the normal fee that you charge similar patients under other programs and/or cash patients. This is also negotiable, so if you provide these services for the payor often, you might want to pre-establish a going rate. You definitely don't want to charge less than Medicare, or the local workers' compensation rate, if there is one in your state.