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Investigational Cash Pricing

  1. #1
    Default Investigational Cash Pricing
    Medical Coding Books
    My clinic does an investiagational procedure that some insurances are willing to pay but others will not. For the patients whose insurance will not pay and we know. We are having the patient sign an ABN and charging them cash. My provider wants to know if there is a stipulation that says the cash rate has to be lower than the lowest allowable carrier.

    My thought is since we are having them sign an ABN like form that tells them their cash rate they will be responsible for we are ok.

    Can anybody help clear this up?

    Thank you
    Kim

  2. Default
    I think you have two issues here

    1) Can you charge patients multiple fees for the same procedure based on the type of patient? (Medicare, cash, etc.) That all depends on what state you are in. For instance, in TX, it is illegal to charge multiple fees for the same service (excluding Medicare and Medicaid). You have to review your state's statutes to see if you can bill multiple fees for the same procedure to know if this practice is okay. Charging multiple fees can present problems, so many offices charge one fee that covers the allowable for all. That way, you don't have to remember to charge each patient differently. Some software programs will keep up with multiple fees. I think it is a matter of preference, unless of course, your state prohibits multiple fee schedules.

    2) The ABN form is for Medicare patients and it sounds like this procedure may be provided to non-Medicare patients. If you have a generic form (for non-Medicare patients) that explains the procedure isn't covered by insurance and the patient signs it, then you should be okay.

    Does that make sense?
    Cyndee Weston, CPC, CMC, CMRS
    American Medical Billing Association
    www.ambanet.net/AMBA.htm
    AMBACode Coding Software
    http://www.ambacode.net
    2015 AMBA National Medical Billing Conference
    http://www.ambanet.net/2015.htm

  3. #3
    Default
    thank you for your response

    1) We are charging different fees for different parts of the body performed of. A back will be more expensive than a knee. We are doing PRP code 0232T so the codes have set fees but the # of injections change the fee. We are using a set fee but the provider is wanting to make sure his fee can be higher than the fee schedule for said provider. For example we are contracted with BCBS and the rate they pay is lower than the cash price so if we had a patient who was to pay cash can we be charging them a higher rate than the fee schedule? 0232T is investigational so it is allowed to have a waiver of financial responsibility signed.

    2) I should not use the term ABN the correct term is Financial Waiver. We have been requested by Medica and Preferred One to ensure that we are having the patients sign waivers to inform them that their insurance may not cover any or part of the procedure.

    Make sense?

  4. #4
    Location
    Charleston, South Carolina
    Posts
    641
    Default
    Quote Originally Posted by kimt View Post
    thank you for your response

    1) We are charging different fees for different parts of the body performed of. A back will be more expensive than a knee. We are doing PRP code 0232T so the codes have set fees but the # of injections change the fee. We are using a set fee but the provider is wanting to make sure his fee can be higher than the fee schedule for said provider. For example we are contracted with BCBS and the rate they pay is lower than the cash price so if we had a patient who was to pay cash can we be charging them a higher rate than the fee schedule? 0232T is investigational so it is allowed to have a waiver of financial responsibility signed.

    2) I should not use the term ABN the correct term is Financial Waiver. We have been requested by Medica and Preferred One to ensure that we are having the patients sign waivers to inform them that their insurance may not cover any or part of the procedure.

    Make sense?
    I suggest you review the definition of code 0232T again. Billing for "multiple" injections is incorrect as the verbiage for 0232T states "injection(s)" etc. Therefore, you would only code 0232T one time regardless of how many injections (or what location) you are using. I believe your price issue would then be mute, as the price would be the same each time you used 0232T.
    Last edited by mmorningstarcpc; 09-22-2010 at 05:35 AM.
    Machelle Morningstar, CPC, COC, CEMC, COSC
    AHIMA Approved ICD-10-CM/PCS Trainer

  5. #5
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default
    And may I add that, based on your contracts, you usually cannot charge LESS to a cash patient than you would to the insurance company, not the other way around. Usually, per your contracts, if you do charge less, the insurance company can lower your allowed to that amount. So, check your contracts with the insurance companies concerning this.

    Hope this helps,
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

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