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Improper multiple procedure reductions.

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Questhrr.com:
Hello Kristin,

Again, thank you.

I have to admit that I'm a little perplexed at this whole issue because like you, when I look up those codes, I get prices wayyyy less than what they billed here. However, even though UHC paid $104.99 for code 64450, per their repricing sheet, that's 10% of UCR which means they consider UCR for this code to be $1,089.90 instead of the billed amount of $1,458.70.  And, when viewing other EOB's for this client, Cigna paid an allowed amount of $728.83 for the same code and Aetna allowed the entire amount billed.

So, I must really be missing something.  I cannot figure out how they come to these rates, but it seems that payers are considering these rates at just under UCR.

Could it be that they are figuring in billing for both provider and facility?  I'm just guessing because as I said, I know nothing about coding and billing.  But even though I cannot generate amounts close to theirs, they claim that its at 300% of Medicare and the EOBs I get for this client shows that other payers are paying just under their billed amounts.

I'm really confused!!!!!!

kristin:
I am just as confused as you! Even if it was both provider and ASC payments in one, the provider allowed amounts are not that much greater with Medicare than the ASC ones. Because I have zero experience in billing ASC, I have to be missing something here, but I don't know what.

Questhrr.com:
Well thank you anyway for your input and honest answers.  :)

Michele:
Wow kristen!  Great info.  I totally missed that it was the ASC and the amounts do indicate that.  I just got caught up in UHCs response.  I agree that even if the provider is out of network the patient should not be charged excessively.  I'm curious as to why a patient would agree to go to an ASC that did not accept their insurance.  Anyway, thanks for sharing such good info.  We used to bill podiatry but haven't for a few years now.

kristin:
Thanks, Michele!  :D

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