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Fee Schedule Question

  1. #1
    Question Fee Schedule Question
    Exam Training Packages
    I am looking for documentation to support a discussion on fee schedules. I have been notified that it is illegal to have mutliple billing fee schedules per Medicare. I have went to the CMS website and there is a million hits on fee schedules! Thanks!!

  2. #2
    What exactly do you mean by multiple fee schedules? You have to have different fee schedules for each payer - they're all based on your individual contracts. Medicare should only have one fee schedule for your area. Commercial fee schedules have to have higher allowables than Medicare (you can't charge a private insurance less than the government), but that's the only rule that I'm aware of.

  3. #3
    I know it sounds a little out there...I have been told that an office can only have 1 billing fee schedule because Medicare says so, it is illegal and Medicare will fine you for it.

    I agree that they are based on individual contracts. Medicare does only have one fee schedule for our area. I am talking more on billing fee schedules and not expected fee schedules.

    Does this help? I went to the CMS website this morning and searched for over an hour.

    Thank you for assisting in this matter!!!

  4. #4
    Question No more consultation codes 99244 or 99254?
    We are not longer using consultation codes right? 99241-99245 or 99251 to 99255?

  5. #5
    If they're not a Medicare contractor, then they don't know what they're talking about. We have dozens of fee schedules - one for the Blues, one for Cigna/Great West, one for Teamchoice, One for UHC (actually, 2 for UHC becaue of one of our providers), and so on...Medicare and Medicaid are the only ones with set fee schedules across the board. Commercial contracts are negotiated annually, and vary from practice to practice.

    Now, if this is an issue of a supplemental policy not having the same fee schedule as the primary payer, then they may be technically correct. You have to honor both, if they don't coordinate benefits. That means, if the primary has a high allowable and happens to pay more than the secondary allows, you have to write off the balance as a contractual adjustment. Let me give a couple of examples:

    For these examples, let's say you billed a 99213 at $100 to primary payer A, and secondary payer B.

    #1 Payer A allows $95 and pays $70, leaving a $25 copay. Payer B only allows $65, and denies payment, because another payer has paid the full allowed amount. You have to write off the $25.

    #2 Payer A allows $80, and applies it to deductible. Payer B allows $60 and pays $40. You may only bill a $20 copay.

    #3 Payer A allows $75 and pays $50. Payer B allows $95 and pays $75. You call to verify that they paid correctly as secondary, and if they did, you refund the patient $50.

    I'm looking for some actual regulations, but the only one I can think of regarding fee schedules is the one I mentioned earlier, which I think is a provision of OBRA. I'll let you know when I find it, though.

    I don't know if the consult codes have been deleted for 2011, because I haven't seen the new CPT, but if they're still in there, they're still valid codes. Medicare no longer recognizes consult codes, though - but that began in 2010.

  6. #6
    Thank you for your time. I agree completely with you. It is trying to prove and justify the reasoning to upper management.

  7. #7
    That's always the hardest part...

    CMS's website is a tangled mess, but I believe if you search terms like "COB" and "anti-kickback statute", you may find what you're looking for. (You'll have to refine those searches, but it's a place to start) The OIG's website also has all of the regulations, but it's not any more user-friendly, and there are lots of actual pieces of legislation to sort through. (Get familiar with your lawyer-lingo).

    Good luck, and if I can do anything else to help, let me know!

  8. #8
    Milwaukee WI
    Default One fee schedule
    We have ONE fee schedule. But we make contractual adjustments based on the MANY contracts we have with various payers.

    So, for example, let's say that our Fee for CPT 12345 is $425.00. That is what we bill to every payer. Per Payer 1's contract with us, P1 pays $300.00 for CPT 12345. Per Payer 2's contract, they pay $400.00. Payer 3's contract only allows $85.00. Etc ... as long as we have a contract in place to accept that payment, we write off the balance as contractual adjustment. Please NOTE This is an EXAMPLE with a fake CPT and fake pricing, just for illustration purposes.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  9. #9
    I agee with F Tessa - you have one fee schedule and adjust according to your contracts, but everyone is charge the same $ amount.

    Charla, CPC, CASCC

  10. Default Fee Schedule
    My experience in the billing industry has been that generally one fee schedule is used for all payers as well as self pay patients. I don't believe it is illegal to have multiple schedules. But you have to tread carefully with multiple schedules. And administrativally multiple schedules can be a challenge . The trick with fee scehedules is that the fees are appropriatte but high enough that the practice is maximizing reimbursement.
    Anything approaching 100% reimbursement from non contracted payers is usually an indication that the fee schedule should be updated.
    Jim S

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