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Thread: Private Pay Pricing Eye Exams

  1. #1
    Join Date
    Apr 2007
    Durham, NC

    Default Private Pay Pricing Eye Exams

    AAPC: Back to School
    This question is related to the "multiple fee schedule" question.

    Can we legally charge one price to a private pay patient and a different price to a Medicare beneficiary? My specialty is optometry/ophthalmology. Our comprehensive exam code 92014 is set at around $115 for Medicare; however, our doctors only want to charge $89 for a "routine" eye exam including refraction, and justify it by saying we can use the S-Codes (S0621). BUT, my compliance officer says the OIG will take into consideration "like procedures" when determining whether we are overcharging Medicare beneficiaries, and therefore the routine vision exam and medical vision exam need to be the same price.

    I have the same question regarding retinal photography (92250). Our doctors like to do this test as a screening, in the absence of medical necessity. Can they legally charge a patient a "screening" fee that is lower than Medicare's allowed amount? Medicare allows around $70 for this test but the docs only want to charge $29 when done as a screening. There is no cpt code for retinal photography screening, so we would have to make one up and never bill it to insurance, I'm guessing.

    We have been arguing this problem back and forth for a year- help!

  2. #2
    Join Date
    Apr 2007
    Concord, NC or Rochester, NY


    No fee should be lower than the Medicare - period. If it is, then Medicare has the right to come back and indicate the practice has charge Medicare too much and take money back. Saying they are using a different code will not matter if the service is the same. Medicare has people out there that will pose as a self pay and then you are caught.

    It is a very dangerous practice that I recommend you stay away from.

    The practice could use the U&C rate and then discount from there for payment at time of service. However, there needs to be logic to substantiate this if it goes below the medicare rate that can be substantiated.

    Here is one link that might help you


  3. #3
    Join Date
    Apr 2007
    Durham, NC


    Thank you, you have given me some more fodder for my battle with my docs.

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