Medical Billing Forum

Payments => Insurance Payments => Topic started by: pvtbiller on February 26, 2013, 09:28:34 AM

Title: Billable Threshold
Post by: pvtbiller on February 26, 2013, 09:28:34 AM
Good Morning,
I had a question that may seem odd but possibly not.  Is there are common "threshold" with insurance carriers  of say $5000 or $10,000 that sends a red flag and prompts further investigation to process and authorization or payment?  To clarify, if you work with the Veterans Administration, if you provide a product that if over a $3000.00 limit, the normal department cannot process it and it need to go to a "contracting" department because of the monetary value.  Are insurance companies structured the same way?  If we are providing equipment and our distributor is up charging to almost the cost of a surgery to correct the issue the patient is having, wouldn't it send a message to make sure that the patient really needs it because of the price point?  Any thoughts?
Title: Re: Billable Threshold
Post by: PMRNC on February 26, 2013, 10:05:46 AM
Yes, carriers do have threshold's but they are internal and administrative meaning NOT on paper, not discussed.  There are different types of thresholds, some may be a simple as a dollar claim value PER examiner authority. When I started for example with one company, my threshold was $5,000 the longer I was there the more I was able to release w/out the threshold. That threshold is merely internal to check for quality. There are also thresholds set PER CARRIER and again, these are internal. There can even be thresholds for certain Plans, certain providers, you might even call some of these "red flags".  There's NO way to answer your question as there is NO set threshold in the manner in which you are talking about. We did indeed have thresholds for DME billing, a few atually. One was dollar amount, one was company red flags and there were also a few things that DME claims get reviewed for in regards to cost. Can they pay a cheaper price somewhere else? Does the patient require a purchase or will a rental be more appropriate? are just a couple of questions that are asked during the claims analysis by a carrier. Of course the first thing looked at is the RX/physicians order and diagnosis.  Certain DME companies might also have their own thresholds due to a red flag for one reason or another. I seen a lot of flags with DME and Laboratories in my days working as an examiner.