Wiki POS for reimbursement

sdb67

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Good morning

I’m not sure if this is the right group to ask this question but here it goes:
We have a group that wants to reimburse claims by the provider specialty only and not look at POS. Is this a normal practice? I have never heard that the POS isn’t taken into account.. they are telling me this is industry standard
Any information you can provide me with would be appreciated. I don’t want to keep pushing back if I have missed something

Thank you in advance
 
Hi there, are you talking about the group's internal policy for how it pays members of the group, or are you talking about how claims are submitted?
 
Example:
Claim is submitted by CRNA, POS 24, CPT 85025. The network I’m working with states that the POS is not taken into account for reimbursement of this claim. As long as the provider specialty can bill the code it is acceptable to pay. I don’t agree with this. And want to make sure I’m providing accurate guidance. I wouldn’t want CMS/ OIG to audit and we are not in compliance with guidelines/policy
 
Example:
Claim is submitted by CRNA, POS 24, CPT 85025. The network I’m working with states that the POS is not taken into account for reimbursement of this claim. As long as the provider specialty can bill the code it is acceptable to pay. I don’t agree with this. And want to make sure I’m providing accurate guidance. I wouldn’t want CMS/ OIG to audit and we are not in compliance with guidelines/policy

Medicare and likely most other payers would reimburse a lab based on a lab fee schedule. It may be accurate that the POS doesn't affect the amount reimbursed.

You still have to report the POS on your claim to bill correctly. The payer will reimburse your claim according to your contracted amounts. Those contracted amounts may or may not be impacted by the POS.

For example, some physician codes may have different facility and non-facility rates. The facility rate for the physician is lower, because the physician is billing for just the professional time/expertise and the facility is billing for the overhead/resources used. The non-facility rate is higher, because the physician is billing for the full service (overhead expenses and their time/expertise). Other CPT codes would reimburse the same amount regardless of POS.

85025 does not have a professional/technical split. The full rate goes to the entity that performed the service.
 
Medicare and likely most other payers would reimburse a lab based on a lab fee schedule. It may be accurate that the POS doesn't affect the amount reimbursed.

You still have to report the POS on your claim to bill correctly. The payer will reimburse your claim according to your contracted amounts. Those contracted amounts may or may not be impacted by the POS.

For example, some physician codes may have different facility and non-facility rates. The facility rate for the physician is lower, because the physician is billing for just the professional time/expertise and the facility is billing for the overhead/resources used. The non-facility rate is higher, because the physician is billing for the full service (overhead expenses and their time/expertise). Other CPT codes would reimburse the same amount regardless of POS.

85025 does not have a professional/technical split. The full rate goes to the entity that performed the service.
So the other example was
A dentist performed a service on a pt at a laboratory POS. If the code billed by the dentist is allowed you would t take into account the POS
 
Good morning

I’m not sure if this is the right group to ask this question but here it goes:
We have a group that wants to reimburse claims by the provider specialty only and not look at POS. Is this a normal practice? I have never heard that the POS isn’t taken into account.. they are telling me this is industry standard
Any information you can provide me with would be appreciated. I don’t want to keep pushing back if I have missed something

Thank you in advance
It is not industry standard. The reimbursement for some procedures is not affected by POS but for other procedures it does make a difference. This is known as a 'site of service differential', and usually applies to procedures that can be performed both in a facility and in a private office. Physicians who perform procedures in a facility will have a lower rate of reimbursement because the facility is billing a separate claim for the use of their space, staff time, supplies and other resources. When the same procedure is done in a private physician-wned office, then a higher rate is paid to compensate the physician for those same resources since an office cannot bill a separate facility claim. It would be unwise and fiscally irresponsible to reimburse the same rates across the board without taking place of service into account.
 
Right, as others have noted, most lab services are not paid under the same fee schedule (or rules) as procedures and visits. It's great that you're being cautious and asking questions.
 
Example:
Claim is submitted by CRNA, POS 24, CPT 85025. The network I’m working with states that the POS is not taken into account for reimbursement of this claim. As long as the provider specialty can bill the code it is acceptable to pay. I don’t agree with this. And want to make sure I’m providing accurate guidance. I wouldn’t want CMS/ OIG to audit and we are not in compliance with guidelines/policy
Under Medicare policy, a clinical lab service would never be payable to a professional provider for place of service 24 because all labs in that POS are the responsibility of the facility and are inclusive to the facility's APC payment rate. A CRNA may be reimbursed for a lab in performed in their office, assuming they own the lab equipment and have the proper certification, but that provider may not bill for a lab performed in a facility. So I agree with you, you absolutely do need to take POS into account if you're aiming to be compliant with CMS reimbursement methodology.
 
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