Medical Billing Forum
General Category => General Questions => : KathyG November 07, 2011, 11:36:00 PM
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Could anyone tell me how to find the "reasonable & customary" fee-for-service rates for LCSW's, psychologists, and psychiatrists under Medicare and Medicaid? All I could find on the CMS website was that HORRIBLE formula!!! it's way too complicated for my brain ???
Thanks!
Kathy G.
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Are you trying to develop a fee schedule for them or are you looking to see what Medicare actually allows? If you go to the Medicare website for the area (not CMS) they have their fee schedules posted. For example, for NYS you would go to www.ngsmedicare.com, click on the appropriate region, and then click on fee schedule. If I'm helping develop a fee schedule I take the Medicare allowed amount and go between 130 - 150%.
Hope that helps!
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I LOVE this forum! :-*
Michele, could you expand a little more on this for me? I know nothing about Medicare/Medicaid. I am actually trying to help a physician set his fees, as I think they're too low compared to what I've seen, and I believe practitioner fees are calculated according to the M/M allowable rates. I think Highmark handles M/M for NJ...so I went to their site and found an area where you can put in the procedure code and it comes up with a rate for you, broken down by "Par - $164.03," "Non-Par $155.83," and "Limiting Charge - $179.20" for a 90801 code. (Actually, I didn't realize you could bill M/M if you're non-participating.) To make a long story short, could you help me determine how one sets a fee off of one of these numbers? I have lots to learn in the area of M/M. Am I correct that out-patient mental health would fall under Part B? Please keep in mind that math isn't one of my strong points, so please spell out your response so a 5-year-old could understand it? :-[ LOL!
Thanks so much...
Kathy G.
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mental health if set as office it would be medicare part b
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Thank you, Regina :)
Kathy G/
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OK so for the 90801, you would take the "par" amount of $164.03 and multiply it by 130% which is $213.24 and by 150% which is $246.05. Then you would set (or suggest) a fee for 90801of $225.00 or something else in between $213.24 and $246.05. See how it's done?
You can be a Medicare provider but be non par. They pay 5% less but you can charge up to the limiting fee. Problem is money goes to the patients. Unless you accept assignment but then you have to accept the non par amount and can't charge the limiting fee, so basically you are non par, agreeing to be par but at 5% less than what the real par provider are. JMO
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Thanks, :D free time! LOL
Take care...
Kathy G.