Medical Billing Forum
General Category => General Questions => : dfranklin May 30, 2009, 07:42:11 AM
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Can a provider have different fee schedules for different billing types? IE one fee schedule for WC, one for Cash, One for regular insurance carriers etc. I thought this was illegal?
Thanks!
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Do you mean the provider is charging a different price for WC cases, Cash clients, and insurance carriers??
If so, no he can't do that.
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Its not illegal to have multiple fee schedules, but there are many things wrong with having multiple fee schedules.
The first being the reporting... carriers determine fee schedules by statistically watching and gathering data from providers, a provider reporting the allowable doesn't report properly thereby knocking the system off..
The second reason is data and accuracy. Let's say a year or two down the road the doctor wants to know..hey which carrier is dead weight for me and show me where I am losing money. You can't because you didn't put in the adjustments and bill "your" fee.
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He said fee schedule, but I didn't interpret him to mean the fee schedule he is contracted with in regards to the payors. (IE his BCBS fee schedule, his Medicare fee schedule, his WC fee schedule etc etc) The way he is reimbursed by these providers. I read it as he (the provider) is billing Comp, insurance, private pay differently. The provider has a different set charge per payor.
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Maybe I did misunderstand..
I thought he meant billing each carrier according to their fee schedule rather than ONE fee set in the office per provider
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Let's see if he responds, because it can be taken either way.
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He is actually Non Par with all providers. And I did mean he bills Workers Comp differently fees than Cash than Insurance (All not contracted with).
Thanks!
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You mean non-par with all carriers right?
Yes there can be a potential for a problem if he is billing different for cash/insurance patients than WC claims. Is he inflating costs? Is he billing the attorney's with LOP's? or maybe there are negotiated fees? Before I say it's wrong there's a lot more information that would need to be given. He could also be charging for records and attorney's.. etc.
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Yes I did mean Non Par with Carriers.
For example 97014 for cash is $10, for insurance is $30 and for workers comp it is $30 or
97110 for cash is 0(Zero), insurance $40, $33 or
97124 for cash is $30, insurance is $45 and wc is $22.14
Thanks!
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Yes, there are a lot of problems with that type of billing especially if he has Medicare patients!
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He does not take medicare either.
Is it the biller's position to explain this to the provider? What are the problems? What are the ramifications on the providers end if he continues billing this way? Biller's end?
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You should advise him of the things he is doing that are not right. Many times they just have no idea that they are doing anything wrong. Have a suggestion for him for what he should do.
For workers comp patients you are suppose to bill out at the workers comp fee schedule amounts.
Michele
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actually for comp, u don't have to bill at the fee schedule, just know that they will only pay whats listed on the fee schedule at the approved amount. each carrier should be billed the same for each code.
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I don't know if that varies from state to state but I got a call from the NYS Insurance Commissioner for one of my providers because we billed a WC claim out at regular fees.
Michele