How to find allowed maximum amount per code of insurance companies

[vchere6535]

Does any one have experience in finding out what the maximum amount billed per CPT code and how to find these criteria from insurance companies? Are we soppose to go by what the doctor tells us he bills? (Does a doc receive a fee schedule when he/she PARed with the insur. co?) If the doctor wants to know how much he can bill to insurance co he does not participate with, what do you tell him? To bill his regular amount and have the inusrance pay what they allow, or will the claim be denied completly this way? thanx

[alaughlin]

If you are in-network with the ins. company, you can call and ask for their fee schedule or you can download their schedules on-line. 

[Pay_My_Claims]

Does any one have experience in finding out what the maximum amount billed per CPT code and how to find these criteria from insurance companies? Are we soppose to go by what the doctor tells us he bills? (Does a doc receive a fee schedule when he/she PARed with the insur. co?) If the doctor wants to know how much he can bill to insurance co he does not participate with, what do you tell him? To bill his regular amount and have the inusrance pay what they allow, or will the claim be denied completly this way? thanx

if you bill less than the allowed you will not receive the full maximum benefit I can tell you that. He should have already had his fee schedule established.

[DMK]

It's really important that you get the allowed amounts from several companies and make sure that your U&C is higher than that.  In California, Blue Cross cuts our bills over 50%, Blue Shield pays better, AETNA pays even better.  If your U&C is too low, it can cause the insurance companies to lower the allowed amount the next time their schedule is set.

We got our first raise on Blue Cross in 10 years this year (we get an extra $1 per visit, WOO HOO!).  Blue Shield, however, reduced our allowed amount.

Your doctor's fee schedule should be looked at annually to make sure you're getting all that you can, and to make sure you're billing the right codes!

[Sportsmom]

I would go to the Medicare fee schedule and make sure you are higher than Medicare. I just did that for our office and had let the doctor know she lost money last year, because our biller did not know anything about the fee schedule and we did not bill to Medicare max allowed. We now bill 10 % over Medicare.
I all so go the CMAC web site for TRICARE to make sure we are above there fee

[Pay_My_Claims]

It's really important that you get the allowed amounts from several companies and make sure that your U&C is higher than that.  In California, Blue Cross cuts our bills over 50%, Blue Shield pays better, AETNA pays even better.  If your U&C is too low, it can cause the insurance companies to lower the allowed amount the next time their schedule is set.

We got our first raise on Blue Cross in 10 years this year (we get an extra $1 per visit, WOO HOO!).  Blue Shield, however, reduced our allowed amount.

Your doctor's fee schedule should be looked at annually to make sure you're getting all that you can, and to make sure you're billing the right codes!

What specialty are you billing where you get good reimbursment from Aetna?? They are lower than medicaid!!

[Michele]

A common rule of thumb is to go between 125 - 130% of the Medicare participating provider allowed amount for your area.

Michele

[DMK]

Since I bill chiropractic, I can't really use Medicare as the basis for our fee schedule since they ONLY pay for spinal manipulation.  Aetna pays well for chiropractic, covers modalities and massage therapy, and CostCo employees have Aetna insurance (big employer in our town).  I have found that Blue Shield pays the best for modalities and exams.

[PMRNC]

U&C and "Allowable" are NOT the same. An insurance company is NOT allowed to give you U&C. If you are non par without an established fee schedule the procedure is to do a pre-determination of benefits. Your expected CPT code and YOUR fee for that CPT code goes to the carrier. They will either tell you YES the fee is within U&C or tell you the amount it's over.. Your bill when billed had better match that pre-d unless there were other circumstances involved and then it should be documented to reflect the fee difference.  Allowable's are based on the fee schedule with the carrier you par with. These can be disclosed but every carrier has a procedure to which they are disclosed and even how often.

[thatcuteblonde]

If you're using Medisoft you can set different fee schedules for different isurance companies, i.e. you can bill Medicare the allowable amount saving you the trouble of taking the adjustment and still bill Worker's Comp their allowable, if they have one. Underbilling will lose the doctor money, but at the same time you don't want to inflate your A/R unnecessarily. If your software doesn't allow you to use multiple fee schedules, use the W/C fee schedule if your state has one. I wouldn't bill less than 125% to 150% of the Medicare fee schedule.

[PMRNC]

It is NOT efficient for a practice to have multiple fee schedules. Not only does it NOT reflect a true A/R, but it also hinders other providers because benchmarks are not accurately being recorded which is how the insurance company comes up with their schedules. Another reason why it's not efficient is because when it is time to review contracts you cannot accurately assess contractual write-off's and adjustments.  As a consultant once I tell providers this they are fine with sticking to ONE fee schedule and then making the proper adjustments.