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Insurance Reimbursement

  1. Default Insurance Reimbursement
    Medical Coding Books
    Just saw a couple of eob's from a southern california surgery center. They had billed Knee Scope, Hammertoe, and ENT procedure. Reimbursement on scope was $55000.00 (Blue Cross) Hammertoe on 2 toes $67000.00 (Aetna) and Septoplasty $55000.00 (Aetna). There were six eob's for a total of $300,000.00 in receipts. Could not believe this. Wondered if this is a common reimbursement in southern california. I think the fee schedule was 10 times Medicare.

  2. #2
    Location
    ENGLEWOOD/DENVER
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    2,338
    Default
    Quote Originally Posted by kd2471 View Post
    Just saw a couple of eob's from a southern california surgery center. They had billed Knee Scope, Hammertoe, and ENT procedure. Reimbursement on scope was $55000.00 (Blue Cross) Hammertoe on 2 toes $67000.00 (Aetna) and Septoplasty $55000.00 (Aetna). There were six eob's for a total of $300,000.00 in receipts. Could not believe this. Wondered if this is a common reimbursement in southern california. I think the fee schedule was 10 times Medicare.
    WHATTTTTTTTTTTTTTTTTTTT!!! NO way!!! Something doesnt seem right with any of that.

  3. Default
    Pretty shocking, huh? I find this a little unethical even though they are an out of network facility. That seems to be the norm today. Then they only charge the patient the copay they would pay if they were in-network. It's no wonder everyones premiums are skyrocketing. I believe in fair reimbursement.

  4. #4
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    Quote Originally Posted by kd2471 View Post
    Pretty shocking, huh? I find this a little unethical even though they are an out of network facility. That seems to be the norm today. Then they only charge the patient the copay they would pay if they were in-network. It's no wonder everyones premiums are skyrocketing. I believe in fair reimbursement.

    what happened to reasonable and necessary? They just paid everyones wages, bonuses and lunch for the next three months on 3 cases!! Holy **** batman!!

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default Decimal point
    You sure they didn't have the decimal point in the wrong place? (Shaking my head.)

    F Tessa Bartels, CPC, CEMC

  6. Red face
    does anyone else see this type of reimbursement? that seems crazy! have you heard how places that take a lot of out of network cases do? Just curious

  7. Default
    I have had some dealings with out of network. Usually what the facilities do is tell the patient they will not pay any more than if they were going to an in-network facility. So if they are a 80/20 plan they take what medicare allows for ASC multiply it times 2 or three and have the patient pay their percentage based on this. The problem with this is you cannot project your financial situation very well.Lets say you are not contracted with Blue Cross they may have a $540 or $380 out of network max and a $500.00 copay. It seems more and more insurance companies are making out of network a flat amount.The places I have been billing for look at if they do 10 scopes and only get $540.00 or $380.00 a case plus copay but get one payment of $20,000.00, that makes up for it. The problem is the writing off amounts that are put towards the patient for payment whether it applies to out of network. Go figure!!!!!!!!

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