Medical Billing Forum

Billing => Billing => Topic started by: Sportsmom on March 04, 2011, 01:17:14 PM

Title: fee schedule
Post by: Sportsmom on March 04, 2011, 01:17:14 PM
I'm billing for a provider that has been charging the Medicare allowable only on his claims, I stated to him you should bill the same has you do for all other clients. You cannot get in trouble for setting your own fees. You still will only get the M/C allowed amount. I did the RBRVS for him and set new fees.
He asks me if I can show him in writing, but I donít have it in writing itís one of thing you just know from billing. Does anyone know if I can find it in writing?

Thank you
Title: Re: fee schedule
Post by: PMRNC on March 04, 2011, 02:46:38 PM
The last time a provider asked me to show it to him in writing, I terminated them. I have NO tolerance for that kind of crap, especially when dealing with Medicare!  Seriously If you are going to give him something to back up common sense.. I would charge him for a consulting fee!.  Remind him why he hired you!

It's like saying .. Prove to me that it's illegal to rob a bank!
Title: Re: fee schedule
Post by: rdmoore2003 on March 04, 2011, 03:34:22 PM
OMG  Is he not charging the same price across the board.........you might want to rethink your position...
Title: Re: fee schedule
Post by: PMRNC on March 04, 2011, 04:37:25 PM
The more I think about this the more It irks me. LOL  (no offense to you) I would give him a choice.. take your advice and training OR get an attorney to put it in writing he CAN do what he wants and charge whatever he wants  :o 

OR Better yet..

Tell him YOUR position.. technically you cannot legally continue with that line of billing anyway because now you have knowledge of it. I would tell him this and let him get someone else to break the law or prove it.
Title: Re: fee schedule
Post by: Sportsmom on March 04, 2011, 09:51:45 PM
Thank you for your help. Glad to know that I'm doing the right thing.

I put his new fee's in writing and had it state, that all clients will be billed the same fee across the board for each CPT code his office bills for
. I will be meeting him on Saturday and going to make him sign and date and having it notarized.

I'll keep you all posted on what happens.
Title: Re: fee schedule
Post by: PMRNC on March 05, 2011, 09:09:38 AM
Quote
I put his new fee's in writing and had it state, that all clients will be billed the same fee across the board for each CPT code his office bills for
. I will be meeting him on Saturday and going to make him sign and date and having it notarized.

Good job, and it's not like you won't know he's not doing it since you will be billing :)    My frustration was not with you but FOR you. Hope you know that :)
Title: Re: fee schedule
Post by: Sportsmom on March 05, 2011, 04:31:23 PM
Yes I did. I just took over two weeks ago for him. What a mess it is. Thank you again for you help I'm so glad you are all here to check with. 
Title: Re: fee schedule
Post by: dekenn on March 07, 2011, 10:06:47 AM

.. technically you cannot legally continue with that line of billing anyway because now you have knowledge of it. I would tell him this and let him get someone else to break the law or prove it.
[/quote]
I thought it was just illegal to bill Medicare more than you bill anyone else. If you're just putting the allowable on the claim, why is that illegal? I can see how it can become complicated changing "fees" according to insurance companies, but that's a bookkeeping issue.
Title: Re: fee schedule
Post by: PMRNC on March 07, 2011, 06:05:42 PM
From Medicare site:

"Some practices charge for procedures based on the Medicare-allowable amount, automatically write off the difference between what they normally charge for the procedure and the Medicare allowable, and bill Medicare the allowable. Then, when Medicare pays its 80 percent of the allowable, the practice can easily determine and record in its billing computer system the 20 percent owed by the patient. Practices do this to avoid billing patients more than their 20 percent of the allowable, which is a violation of Medicare law.[/u]
 
The problem with automatically writing off the difference between what you normally charge and the Medicare allowable and billing the allowable amount is that you are, in effect, reducing your charge to Medicare. Dont confuse charges with payment. Your charges should be the same for everyone, regardless of payer. What you charge for a procedure is based on several factors, such as your costs for supplies, personnel, facilities and services, and a small profit. If your other contracted payers discover you charge Medicare less than you charge them for the same services, they will demand the same discount. Having different charges for the same services could increase your chances of an audit by CMS, which runs Medicare. Because your charges are different for the same services, Medicare will check whether you are charging it more than other payers, which Medicare considers fraud and abuse, and whether you are making false claims to the federal government. When you submit the amount of allowable or the amount of expected reimbursement as the charge to Medicare, you are not giving the federal government a true picture of charges for the services. That can affect the level of reimbursement the government decides to pay for Medicare patients."
Title: Re: fee schedule
Post by: dekenn on March 08, 2011, 08:43:53 AM
That to me, says that it's better that you bill everyone the same, but not that you're legally bound to.  I read the statement, "Practices do this to avoid billing patients more than their 20 percent of the allowable, which is a violation of Medicare law" as meaning.. It is a violation of Medicare law to bill patients more than their 20 percent of the allowable.  The object of the phrase "which is a violation of Medicare law" is "billing patients more than their 20 percent..."

Not that I'm arguing the common sense of it... I just don't think it's "illegal". Yes, it may raise red flags, yes, it may get you audited, yes, it may get you in trouble with other insurances, but not "illegal"
JMO
Title: Re: fee schedule
Post by: PMRNC on March 08, 2011, 12:36:40 PM
Quote
"Some practices charge for procedures based on the Medicare-allowable amount, automatically write off the difference between what they normally charge for the procedure and the Medicare allowable, and bill Medicare the allowable. Then, when Medicare pays its 80 percent of the allowable, the practice can easily determine and record in its billing computer system the 20 percent owed by the patient. Practices do this to avoid billing patients more than their 20 percent of the allowable, which is a violation of Medicare law.

I think you misunderstood it..  IT states that practices DO THAT TO AVOID....  In other words, practices that are billing the allowable ARE most likely DOING SO TO AVOID billing patient's more than their 20 percent. It's merely a reason as to why providers would do it. It is absolutely a violation of Medicare law.

Quote
Not that I'm arguing the common sense of it... I just don't think it's "illegal". Yes, it may raise red flags, yes, it may get you audited, yes, it may get you in trouble with other insurances, but not "illegal"
JMO

It states it IS a violation of Medicare Law.. that means "illegal"
Title: Re: fee schedule
Post by: dekenn on March 08, 2011, 04:34:07 PM
Anyone else have a take on this?
 I still stand by my original interpretation. "Practices do this to avoid...." means that instead of making sure they take the appropriate adjustment, they bill the allowable so they don't have to worry about it.  And, I still say that the phrase "which is a violation of Medicare law" modifies "billing patients more than their 20 percent of the allowable."

I think it's stating that "practices do this" as an informative statement, going on to explain that it's a shortcut of sorts to avoid billing the patient more than 20 percent.  If they bill the Medicare allowable, and that is the amount in their system, when Medicare pays their 80%, the only thing left is the 20%, no adjustments need to be made, etc. 
Title: Re: fee schedule
Post by: Michele on March 09, 2011, 07:51:21 AM
Actually I did some research on this several years ago (I'll avoid the long story as to why!) and I was informed by Medicare that it is illegal for providers not to attempt to collect the 20% balance.  They don't have to collect it, but they have to attempt to collect it.  It is illegal for a provider to just write off the 20% patient responsibility without attempting to collect.  Then they are supposed to document their efforts. 

OK, I'll explain a little.  We were researching for a non-profit local ambulance company.  They wanted to raise revenue by billing insurance but they did not want to collect any monies from patients, since they were a very rural, non-profit, basically free ambulance service.  If I remember correctly they were volunteers.  Anyway, most patients are Medicare so they wanted to know if they could bill Medicare, but not charge the patient for any balance.  The answer was a resounding 'NO'.  But then it was further explained that they needed to ATTEMPT to collect the balance and document those attempts. 

Michele
Title: Re: fee schedule
Post by: dekenn on March 09, 2011, 09:14:56 AM
I don't think the issue was not billing the patient the 20%, I think it was the amount that actually goes on the claim to Medicare.  If a provider puts the Medicare allowable on the claim, Medicare will then pay it's 80% share, leaving 20% patient balance. This whole amount can then be billed to the patient without worrying about whether it's the correct amount or not.... after Medicare pays, the only thing left is the 20%.
For example, if a provider charge for 99213 is normally $100.  Assume Medicare allows $80.00, pays $64.00 with a $16.00 patient balance. The provider now has to make sure the system is set up to make the medicare adjustment of $20.00 to avoid billing it to the patient.  On the other hand, if the provider puts $80.00 on the claim, gets paid the $64.00, the only thing left is the $16.00 patient balance..... no adjustments have to be made.

The downside of this is if you don't update your fees according to the Medicare allowable, you could be billing Medicare LESS than their allowable (yes, occasionally, the reimbursements do go UP!!   ;)  )
Title: Re: fee schedule
Post by: PMRNC on March 09, 2011, 09:41:18 AM
Quote
I don't think the issue was not billing the patient the 20%, I think it was the amount that actually goes on the claim to Medicare.  If a provider puts the Medicare allowable on the claim, Medicare will then pay it's 80% share, leaving 20% patient balance. This whole amount can then be billed to the patient without worrying about whether it's the correct amount or not.... after Medicare pays, the only thing left is the 20%.
For example, if a provider charge for 99213 is normally $100.  Assume Medicare allows $80.00, pays $64.00 with a $16.00 patient balance. The provider now has to make sure the system is set up to make the medicare adjustment of $20.00 to avoid billing it to the patient

What Michele was saying was that by billing the "allowable" Medicare CAN and DOES interpret that to mean the coinsurance is being waived (remember, if it's not documented it's not done, not just in the coding world. Medicare assumes providers are charging what they would charge any other patient.  Medicare pays their portion (%) OF the allowable, by lowering the allowable on your CMS1500 Medicare CAN interpret that to be that the provider has waived the coinsurance.

AT every medicare seminar I've ever attended this comes up.. all the time and the answer is the same. NO. how Michele explained it is how Medicare interprets it.  But like I said, I don't argue this with anyone, I just won't bill it like that. As my attorney always reminds me, worry about your own ass.


Quote
I still stand by my original interpretation. "Practices do this to avoid...."

I still think you are not reading the rest of the sentence which is the most important part, also the law is the law, it's not up for us to interpret it unless we want to end up in a court room paying an attorney.   The rest of that sentence IS the bulk of it and is very clearly stated:

Quote
"Some practices charge for procedures based on the Medicare-allowable amount, automatically write off the difference between what they normally charge for the procedure and the Medicare allowable, and bill Medicare the allowable. Then, when Medicare pays its 80 percent of the allowable, the practice can easily determine and record in its billing computer system the 20 percent owed by the patient. Practices do this to avoid billing patients more than their 20 percent of the allowable, which is a violation of Medicare law.[/u]

Practices do this to avoid billing patients more than their 20% of the allowable, WHICH....... is a violation of Medicare Law.

Now maybe the practice still intends to bill the coinsurance you will say?  That's MOOT because MEDICARE has stated they will interpret the billing practice as illegal.

This is actually stated from my fathers Medicare booklet,on an insert on how beneficiaries can avoid fraud/abuse. I pulled it out of there because it was easier to understand than the legal mumbo jumbo so that Medicare Beneficiaries can be on the look out for fraud and/or abuse by their providers.
Title: Re: fee schedule
Post by: dekenn on March 09, 2011, 09:57:25 AM
How on earth does that mean that you're waiving the coinsurance?????  If the coinsurance is $16.00 using my previous example, and you bill the patient $16.00, how is that waiving the  coinsurance?  If the Medicare allowable is $80.00, again, using my previous example, and you put $80.00 on the claim, how does medicare interpret that as waiving the coinsurance?????? THey will pay $64.00, and show patient balance of $16.00, which is then billed to either secondary or patient, it is in no way shape or form being shown as "waived"!!!!

I stand by my original interpretation.
Title: Re: fee schedule
Post by: PMRNC on March 09, 2011, 09:58:12 AM
OK... It took me a while..BUT I get what you are reading.. I get it now:


Quote
"Some practices charge for procedures based on the Medicare-allowable amount, automatically write off the difference between what they normally charge for the procedure and the Medicare allowable, and bill Medicare the allowable. Then, when Medicare pays its 80 percent of the allowable, the practice can easily determine and record in its billing computer system the 20 percent owed by the patient. Practices do this to avoid billing patients more than their 20 percent of the allowable, which is a violation of Medicare law.[/u]

What you are interpreting.. I get it now..  Practices that bill that way to avoid CHARGING MORE THAN THE COINSURANCE, which is illegal. In other words if they billed the patient $84 instead of $64 (based on your example) that would be illegal. So they do so to avoid that ?  Correct.    I tried to ask my attorney yesterday (he's a Medicare reg wiz, but somewhat a typical attorney with a typical attitude)  I asked:    Is it illegal for a provider to bill Medicare the allowable RATHER than the physician's fee?  His response:  "Of course it is, why would you ask me that".  ??? ???  He scares me a little.. but I will ask him to clarify it, he knows I will anyway.. LOL

I'm sorry it took me few go around to see what you were reading and I agree it can be read that way.
Title: Re: fee schedule
Post by: PMRNC on March 09, 2011, 09:59:21 AM
We were replying at same time. I went back and read it a few more times :)
Title: Re: fee schedule
Post by: MJ on March 24, 2011, 12:58:02 PM
This information brings up another question.  The practice I work for has a policy for uninsured patients.  They have them sign off attesting to the fact that they have no insurance at all.  They have established a discounted fee for these patients of $75 for an office visit.  This does not include procedures, labs, immunizations etc.  It is used for 99213, 99214 type of office visit for a sore throat, Med management, etc.  My question ... is it legal to establish a discounted fee if they bill a different fee to insurance companies?  Can the same be done for preventative visits and procedures?
Title: Re: fee schedule
Post by: rdmoore2003 on March 24, 2011, 02:28:13 PM
if you have all the documentation to back up that the patient says no insurance you are covered.   

For example, a couple of years ago, we started a "hardship" program in our office.  to meet the criteria for this program, patient cannot have insurance or if they do have insurance but no mental health benefits they may qualify.   We have an income fee schedule for this program.   We go soley based on household income before taxes are taken out.   Depending on that income and where they fall on the fee schedule, depends on what they pay.   They must sign off on our form that states what they will pay for intake, 45-50 minute therapy, medication visit, psych. testing, etc.   On the form, it also specifically states that we do not file their insurance (if they have it but no mental health benefits)  It covers us as the provider and also down the road if the patient comes back and says I do have insurance and I will file myself, they need cpt codes and we give them a printout for the insurance company of what our agreement was and invoice showing that what we charged, what they paid, and of course the agreement.   Patients get upset at times that they cant get more money from insurance.   Mental health patients are always trying to pull something......