Wiki Setting Self Pay Rates in Massachusetts

[Cmcgoldrick]

Hello, I am fairly new to using this feature so I apologize if it seems a bit off. I am working with a behavior health practice who are not contracted with insurance, they wish to provide pricing on their website for services BUT they want to also list pricing per provider experience. I disagree with this idea and when I made that clear the Director shot back at me and asked for the Massachusetts statute that prohibits this. I have searched all over for something that is clear but I am not able to find anything. Can you help?

 

[csperoni]

This falls under the realm of compliance, rather than coding or billing, and I would suggest you check with an expert in that area.
That being said, I'll weigh in with my OPINION. If you are not participating with ANY insurances, I believe you may set different rates for different providers.
Like providers A, B & C rate is $150; providers D, E & F is $125. For compliance, usually the issue is consistency. Meaning you can't charge insurance 1, insurance 2, and self pay all different rates. I have zero proof to back this up, but I can't imagine different providers cannot set different rates that are then universally applied to all their specific patients.

 

[haraml7]

Hello, I am fairly new to using this feature so I apologize if it seems a bit off. I am working with a behavior health practice who are not contracted with insurance, they wish to provide pricing on their website for services BUT they want to also list pricing per provider experience. I disagree with this idea and when I made that clear the Director shot back at me and asked for the Massachusetts statute that prohibits this. I have searched all over for something that is clear but I am not able to find anything. Can you help?

I would look at the Medicare fee schedule for your state (MAC carrier) to get an idea of what the prices run for on those specified CPT codes. Those CPT codes are valued already and it does not fluctuate due to provider experience. I would at least get a basis of the pricing on codes and discuss this with my providers. If you have codes where the CPT code is time based, the fee schedule that you pull up in your MAC will only give you the reimbursment for ONE unit. So if you bill for a time based code and it is a 15 min increment code, if you saw the patient for an hour, you would bill for 4 units, so you would multiple the fee schedule amount to 4 units. Please don't hesitate to reach out if you have any other questions.
I am not sure about the statue the provider is referencing on charging the patient whatever amount they choose but, the providers are technically out of network, so they should create a "fair, or good faith estimate" on the CPT codes being performed. I hope that helps.
Thanks
Misty

 

[Cmcgoldrick]

I would look at the Medicare fee schedule for your state (MAC carrier) to get an idea of what the prices run for on those specified CPT codes. Those CPT codes are valued already and it does not fluctuate due to provider experience. I would at least get a basis of the pricing on codes and discuss this with my providers. If you have codes where the CPT code is time based, the fee schedule that you pull up in your MAC will only give you the reimbursment for ONE unit. So if you bill for a time based code and it is a 15 min increment code, if you saw the patient for an hour, you would bill for 4 units, so you would multiple the fee schedule amount to 4 units. Please don't hesitate to reach out if you have any other questions.
I am not sure about the statue the provider is referencing on charging the patient whatever amount they choose but, the providers are technically out of network, so they should create a "fair, or good faith estimate" on the CPT codes being performed. I hope that helps.
Thanks
Misty

Hi Misty, This practice is not contracted with insurance so this is all fee for services, this is why the practice thinks that they have the option to charge different rates for the same service with providers of the same discipline based on provider experience.

 

[Cmcgoldrick]

This falls under the realm of compliance, rather than coding or billing, and I would suggest you check with an expert in that area.
That being said, I'll weigh in with my OPINION. If you are not participating with ANY insurances, I believe you may set different rates for different providers.
Like providers A, B & C rate is $150; providers D, E & F is $125. For compliance, usually the issue is consistency. Meaning you can't charge insurance 1, insurance 2, and self pay all different rates. I have zero proof to back this up, but I can't imagine different providers cannot set different rates that are then universally applied to all their specific patients.

Hi, Thank you for your response, this is the issue on a compliance level as far as I am concerned. I would not think you can charge different rates for providers of the same discipline for the same service because some have less experience. There are no insurance contracts so it is fee for service, so it leaves a hole trying to find something out there that says yes you can or no you cannot.