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Workers Comp vs Commercial Insurance CPT pricing

pkoehler

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Need some advice:

Can a clinic charge different pricing for WC CPT codes vs. Commercial Insurance? Basically, have two fee schedules for our CPT codes.

Thanks
PK
 

dchenkin

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Actually, that depends on the laws of your local jurisdiction. Generally, Workers Comp Boards create their own fee schedules for workers comp claims. In NYS the WCB has a very comprehensive fee schedule that has no relation to what a commercial payor may be billed. So the answer is "it depends" on the laws of your state.
 

CodingKing

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Actually, that depends on the laws of your local jurisdiction. Generally, Workers Comp Boards create their own fee schedules for workers comp claims. In NYS the WCB has a very comprehensive fee schedule that has no relation to what a commercial payor may be billed. So the answer is "it depends" on the laws of your state.
So you don't submit billed charges and take a write off? Just bill the mandated rate to WC?
 

dchenkin

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So you don't submit billed charges and take a write off? Just bill the mandated rate to WC?
To be clear I work for a law firm that provides defense for insurance companies in no-fault auto claims. In NYS the fees for no-fault claims are tied directly to the fee schedule established by the Workers Comp Board. NY's no fault law limits the liability of carriers to WCB schedules. So I would assume that the providers do take the write off from the billed amount vs. the fee scheduled amount. Regarding workers comp claims, while not my area of expertise, I would also assume that workers comp providers who bill above the fee schedule also write off the difference, since the law prohibits billing the patient/claimant for the difference between the billed amount and the reimbursed amount.
 
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CodingKing

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That's what I thought you meant. There are no issues with accepting different reimbursement rates from different payers. That's pretty much standard, some pay more some pay less. The issue is you cannot bill more to one payer than another which is what i think the poster was asking about. Just because one payer has a bigger bank account doesn't mean you can jack up the price to make up for losses by other payers that pay less. If you raise your price, you raise it across the board.
 

dchenkin

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Ok. Essentially the point being your card rate is your card rate regardless of the client or third party payor. But again isn't that kinda moot in this day and age when providers and insurance carriers enter into contracts that include comprehensive fee schedules?
 

Walker22

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Ok. Essentially the point being your card rate is your card rate regardless of the client or third party payor. But again isn't that kinda moot in this day and age when providers and insurance carriers enter into contracts that include comprehensive fee schedules?
You would think so, but Medicare and many commercial insurances have a clause in their network participation contracts that says you agree to bill them them no more than any other payer.
 

CodingKing

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I can see why they wouldn't want to pay more just because they have deeper pockets. A payer shouldn't have to pay more than what would be billed if the patient had no insurance.
 

NJcoder

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Workers Comp/No FAult

So you don't submit billed charges and take a write off? Just bill the mandated rate to WC?
Hi, do you know where I can find the conversion factor for No fault?
Or any sites/links to learn more about workers comp/no fault billing?
I am also looking for the physician RVUs?
Thank you very much!
Laurie
 
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