Wiki Properly setting UCR fees

[cecim11]

Hi. I have been doing billing for many years, private office setting, outpatient. The standard for setting UCR has been 200% of the Medicare fee rates. This is now being challenged by a doctor who wishes to set their UCR differently. I can't find any reference regarding how to properly set UCR. And I am realizing the formula I have been following has been based solely on how I was trained many years ago - no particular rule/regulation stipulating how to formulate UCR. Am I wrong? Can the doctor set their fee rate arbitrarily to whatever rate they like for each service code? As the biller, I don't want to do anything that is not within compliance. Does anyone have any advise? Thank you in advance.

 

[csperoni]

You may set your fees at whatever you wish. The same fees must apply to all patients (barring financial hardship or other rare exception). For commercial insurances that you participate with, you will be paid your contracted rate or the amount billed, whichever is lower. If the rate for 99213 is $150, whether your charge is $200 or $2000, you are getting the same $150.
Most practices realize the higher their fees, the higher the writeoffs. Changing your fees will do very little for revenue unless you have a lot of self pay patients who are willing to pay higher fees.
My personal opinion is that 200% of MCR is a bit low. I personally would set somewhere more like 250-300%. At 200%, I'd be concerned there's an occasional CPT with an occasional carrier who may have a higher rate.
There's also no requirement to use MCR, although it's a good place to start. You may decide 300% of MCR for all procedures, and 200% of MCR for E/M for example.
Compliance comes into play when you are not charging all patients/carriers the same.

 

[cecim11]

You may set your fees at whatever you wish. The same fees must apply to all patients (barring financial hardship or other rare exception). For commercial insurances that you participate with, you will be paid your contracted rate or the amount billed, whichever is lower. If the rate for 99213 is $150, whether your charge is $200 or $2000, you are getting the same $150.
Most practices realize the higher their fees, the higher the writeoffs. Changing your fees will do very little for revenue unless you have a lot of self pay patients who are willing to pay higher fees.
My personal opinion is that 200% of MCR is a bit low. I personally would set somewhere more like 250-300%. At 200%, I'd be concerned there's an occasional CPT with an occasional carrier who may have a higher rate.
There's also no requirement to use MCR, although it's a good place to start. You may decide 300% of MCR for all procedures, and 200% of MCR for E/M for example.
Compliance comes into play when you are not charging all patients/carriers the same.

Thank you so much for this information, I really appreciate it. I share your concerns with ending up with lower fees, particularly now that the doctor actually wants to set some of his fees at BELOW the Medicare rate (while others at 200% of MCR). Your advise makes perfect sense to me and gives me a good basis for where to start looking. Thank you again!!

 

[pihhernandez]

You may set your fees at whatever you wish. The same fees must apply to all patients (barring financial hardship or other rare exception). For commercial insurances that you participate with, you will be paid your contracted rate or the amount billed, whichever is lower. If the rate for 99213 is $150, whether your charge is $200 or $2000, you are getting the same $150.
Most practices realize the higher their fees, the higher the writeoffs. Changing your fees will do very little for revenue unless you have a lot of self pay patients who are willing to pay higher fees.
My personal opinion is that 200% of MCR is a bit low. I personally would set somewhere more like 250-300%. At 200%, I'd be concerned there's an occasional CPT with an occasional carrier who may have a higher rate.
There's also no requirement to use MCR, although it's a good place to start. You may decide 300% of MCR for all procedures, and 200% of MCR for E/M for example.
Compliance comes into play when you are not charging all patients/carriers the same.

Is there a reference source that states that UCR is 200/300% of the Medicare Fee Schedule somewhere?