Author Topic: Billing under supervisor for Blue Cross Blue Sheild  (Read 2728 times)

s0b3k111

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Billing under supervisor for Blue Cross Blue Sheild
« on: August 14, 2018, 09:42:00 AM »
Preface: I am not a medical biller, we have recently let go of our biller and I believe that she was not doing her job correctly.

I help manage a psychological clinic (7 LP, 3 LLP, 5 LMSW, 5 LPC is the licensure breakdown), and previously we billed all of our blue cross claims under our LP's only. They provide direct supervision for all of the clinicians that we submit claims under them for. Our most common CPT code is 90837 as a standard appointment is 60 min for us.

I am wondering a few things:
Is there a way to bill at the LP's rate legally
Is there a way to avoid PGIP, we are not a part of any physician group, and have not been previously charged this.
If the BCBS max allowable for our practice is $160 for LP should we bill $160 or slightly under?
Why is this information so hard to find?

Michele

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Re: Billing under supervisor for Blue Cross Blue Sheild
« Reply #1 on: August 14, 2018, 04:14:29 PM »
I am wondering a few things:
Is there a way to bill at the LP's rate legally

I'm not sure what you mean by this.  Don't you bill all services at the same fee and then let the insurance carrier process at the appropriate rate?

Is there a way to avoid PGIP, we are not a part of any physician group, and have not been previously charged this.

Are you in Michigan?  Are you referring to the BCBS PGIP?  If so, you would have to check with BCBS to find out if you can avoid it.

If the BCBS max allowable for our practice is $160 for LP should we bill $160 or slightly under?
Why is this information so hard to find?

Most medical offices set a fee schedule for their services.  All services should be billed at that fee schedule and then adjusted according to the EOB/ERA.  It is common for offices to set a fee schedule anywhere from 125-160% of Medicare allowed amounts for their area, even if they do not enroll with Medicare.  It's a good gauge to use when setting fees.  For example, if Medicare allows $67.56 for a 90834 the a common fee might be $95.    I hope this is helpful!

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s0b3k111

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Re: Billing under supervisor for Blue Cross Blue Sheild
« Reply #2 on: August 15, 2018, 05:41:29 AM »

I'm not sure what you mean by this.  Don't you bill all services at the same fee and then let the insurance carrier process at the appropriate rate?

Well, previously (and probably incorrectly like I said), all of our LMSW/LPC/LLP billing was done directly under the LP's NPI number (only for BCBS). So we received the rate for an LP. So we did bill at the same fee, but we didn't include modifiers to indicate that there was a lower licence level because our (mis)understanding was that we were able to bill under the supervisors lisence.


Quote
Are you in Michigan?  Are you referring to the BCBS PGIP?  If so, you would have to check with BCBS to find out if you can avoid it.

Yes we are in Michigan, and since we do not participate in any physician organizations, so is there a way to not be forced to pay this fee?


Quote
Most medical offices set a fee schedule for their services.  All services should be billed at that fee schedule and then adjusted according to the EOB/ERA.  It is common for offices to set a fee schedule anywhere from 125-160% of Medicare allowed amounts for their area, even if they do not enroll with Medicare.  It's a good gauge to use when setting fees.  For example, if Medicare allows $67.56 for a 90834 the a common fee might be $95.    I hope this is helpful!

So for us we bill at different rates depending on the insurance (again not sure if that is wrong or not). Aetna at 125, BCBSM at 145, Medicare at 105 etc. Each company has a slightly different cost. I hope that explains it more clearly, and yes you were helpful.


Michele

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Re: Billing under supervisor for Blue Cross Blue Sheild
« Reply #3 on: August 22, 2018, 12:28:32 PM »

I'm not sure what you mean by this.  Don't you bill all services at the same fee and then let the insurance carrier process at the appropriate rate?

Well, previously (and probably incorrectly like I said), all of our LMSW/LPC/LLP billing was done directly under the LP's NPI number (only for BCBS). So we received the rate for an LP. So we did bill at the same fee, but we didn't include modifiers to indicate that there was a lower licence level because our (mis)understanding was that we were able to bill under the supervisors lisence.

This is out of my scope.  I do know that you are not supposed to bill for services provided by one provider under another provider's license unless they are some sort of a supervising provider.  If you are strictly billing under the LP's NPI number in order to get reimbursed or reimbursed higher, that is not ok.  Unless BCBS has stated that they do not credential LMSW/LPC/LLPs and that they allow you to bill under the LP.  So if the LP is supervising the lower level professional and that is allowed in your state, then it would be ok.


Quote
Are you in Michigan?  Are you referring to the BCBS PGIP?  If so, you would have to check with BCBS to find out if you can avoid it.

Yes we are in Michigan, and since we do not participate in any physician organizations, so is there a way to not be forced to pay this fee?

I'm sorry but I'm not sure about this either.  I do not bill for any providers in Michigan so I am not aware of how that works. 

Quote
Most medical offices set a fee schedule for their services.  All services should be billed at that fee schedule and then adjusted according to the EOB/ERA.  It is common for offices to set a fee schedule anywhere from 125-160% of Medicare allowed amounts for their area, even if they do not enroll with Medicare.  It's a good gauge to use when setting fees.  For example, if Medicare allows $67.56 for a 90834 the a common fee might be $95.    I hope this is helpful!

So for us we bill at different rates depending on the insurance (again not sure if that is wrong or not). Aetna at 125, BCBSM at 145, Medicare at 105 etc. Each company has a slightly different cost. I hope that explains it more clearly, and yes you were helpful.



I always recommend that you have one set fee schedule for all services.  Then when insurance payments come in the contractual adjustments are made.  The issue is that you should be charging the same for your services, not different amounts depending on the type of insurance. 
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PMRNC

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Re: Billing under supervisor for Blue Cross Blue Sheild
« Reply #4 on: August 29, 2018, 09:55:20 AM »
I agree with Michele on all counts. You should not be billing for a particular provider under another's license. The multiple fee-schedule also would send up a lot of red flags because of billing under another license. ONE fee schedule is more appropriate for many reasons.
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Re: Billing under supervisor for Blue Cross Blue Sheild
« Reply #4 on: August 29, 2018, 09:55:20 AM »

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