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Thread: Please settle this for me!!!

  1. #1

    Default Please settle this for me!!!

    AAPC: Back to School
    I have a little actually huge argument between the Doctors and I. Please all billers can you help me !!!! The Doctors have NOT updated there contracting with insurance companies since the 1980's. Our reimbursement rates for some commercial insurance is 50 to 70% of what Medicare pays. I am under the impression that Commercial Insurance Companys base there fee schedule on the Medicare reimbursement rate, so we should at least be getting paid at 100% of Medicare. Medicare is our highest payer! If I am wrong I will gladly say so, but I need to settle this. I am in New York Downstate. PLEASE HELP THIS IS SO FRUSTRATING!!

    Have a great Day,

  2. #2
    Join Date
    Apr 2007
    Lancaster, PA


    Since Medicare has adjusted their fee schedule several times since the eighties, I would point out to the doctors how much money they are losing/have lost by not updating their contracts with commercial payers. In our office, we update and negotiate with the companies every year. Not all commercial payers follow Medicare fee schedules for us, but I'd say 75% of them do. I would talk to your reps and get copies of their current fee schedule sent to you for comparison. Good luck!

  3. #3


    Thank you so much for your help, so apprciated.


  4. #4
    Join Date
    Apr 2007


    You'd need to pull the contracts with the payers to be sure. Payers use various methodologies for pricing, but most generally will refer to Medicare as the basis. Most contracts will site a particular Medicare Yr or explain their updating process for determining UCR rates. For the most part you shouldn't settle for less than 150% of Medicare's Allowable (and that's thin).

    If they haven't updated their contracts since the 1980s (and I'm floored by that); They more than likely don't have a competitive fee schedule either. Sounds like you have A LOT of work to do to get this group up to speed. A detailed analysis of their payer mix , pricing, and adjustments is in order here. I absolutely cringe when I hear these reports from my colleagues.

    You'd also want to see if the practices has any % of billed arrangements. They are becoming scare nowadays, but they can be very positive for a practice with a strategic fee schedule.

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