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Thread: self pay vs insurance fee schedules

  1. #1

    Cool self pay vs insurance fee schedules

    AAPC: Back to School
    Does anyone know if there is documentation out there from the OIG or CMS surrounding setting fee schedules at different rates for patients with insurance and self pay. I remember several years ago that there was quite a hoopla about requlations and fraud if providers set different fee schedules.
    I searched the OIG and CMS but with soooo much to waide through I'll be a year older before I find anything.

  2. #2

    Wink MsRivers

    To my knowledge a provider can only have 1 fee schedule. This is a common reason why many providers charge (what seems to be) astronomical fees because insurance carriers all pay differently. If the provider is contracted,then regardless of the set fee, the provider must accept what the insurance pays as paid in full. As far as self pay patients, the provider can choose to give the patient a discounted charge, and adjust the balance; however the fee remains the same.

  3. #3

    Default Reply- Insurance vs self pay fee schedules

    Thanks for the reply. I have the same understanding but we have a provider who told me to send him documentation of this. I haven't been able to locate it. It was released in 2007-2008 regarding the fee schedule issue but I can't locate any documentation. I went to the OIG web site.....
    Any suggestions?

  4. #4


    I agree that you can not have two separate fee schedules as well, you have to charge the same fee. What you accept as payment in a self pay case is different, you can choose to accept a discounted amount for self pays like in cases of financial hardship. Hopefully your dr does not want to charge self pay patients more which I really dont understand. If you are looking for written documentation, I am not aware of anything but to me charging a self pay more just because you can is unethical. I do know that there is one provider that I believe in Massachusetts who has to pay back 26 million dollars because he was charging unreasonable fees and charging different fees for self pay patients and patients who had insurances he did not accept. You may want to look on OIG's website for the documentation involved.

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