Author Topic: usuall and customary charges  (Read 3926 times)

rdmoore2003

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usuall and customary charges
« on: July 02, 2009, 02:58:16 PM »
How, if any, can you find and figure your areas usuall and customary charges for out of network, so that I can figure each client's percent?
Regina

PMRNC

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Re: usuall and customary charges
« Reply #1 on: July 02, 2009, 05:02:03 PM »
U&C is calculated using the HIAA at the 90th percentile, from 1997.. ( I think..)
Insurance carriers will NOT give out U&C

why do you need it to figure out what to charge? If you are charging on a percentage it should be on "total" revenue collected.
Linda Walker
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rdmoore2003

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Re: usuall and customary charges
« Reply #2 on: July 03, 2009, 09:29:19 AM »
I need to know so that out of network clients that are responsible for say 30% get charged correctly, I like to charge accurate fees and not just fly by like some billers that I have met around the country.
Regina

Pay_My_Claims

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Re: usuall and customary charges
« Reply #3 on: July 03, 2009, 10:19:57 AM »
I need to know so that out of network clients that are responsible for say 30% get charged correctly, I like to charge accurate fees and not just fly by like some billers that I have met around the country.

Ok, now I am more confused. If you are billing according to your fee schedule, you can't charge and OON client more because they are OON. I don't know what kind of provider you are billing for, but since I do a lot of DME, I will use that.

In NC I will say a k0005 UCR is 2500. Our fee schedule is such that we bill (all payors) 2300 we are lower than what is usual in our area. Client A comes in for the chair has UHC (we are par) we still bill 2300 to the ins company and the client is still responsible for their portion after the INS company does its adjustments (allowable, ded, coins, pt resp). Client b comes in same chair with BCBS (non par) we still bill 2300 and bcbs will do the adjustments (allowable, ded, coins pt resp), but the DIFFERENCE is we can balance bill them since we are non-par.

PMRNC

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Re: usuall and customary charges
« Reply #4 on: July 03, 2009, 10:27:20 AM »
I'm confused too. Are you a biller? I'm still not understanding what knowing U&C has to do with charging your client. Anything above U&C on a charge is going to be patient responsibility..you are still charging/billing the patient and should be collecting the amounts over U&C or Copay for In network?
Linda Walker
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Michele

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Re: usuall and customary charges
« Reply #5 on: July 03, 2009, 11:24:38 AM »
If you are out of network, doesn't the payment go directly to the patient, and you just charge your regular fee schedule?  The patient has to pay the whole thing right?

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Pay_My_Claims

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Re: usuall and customary charges
« Reply #6 on: July 03, 2009, 11:47:15 AM »
If you are out of network, doesn't the payment go directly to the patient, and you just charge your regular fee schedule?  The patient has to pay the whole thing right?

Michele

No, not all carriers will pay directly to the client. The one that I know that does that is BCBS-NC even if you file assigned. Other carriers will still pay directly to you, unless you bill non-assigned and collect 100% up front.

PMRNC

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Re: usuall and customary charges
« Reply #7 on: July 03, 2009, 03:08:10 PM »
BCBS will not honor assignment of benefits. A few states have taken them on in court over this and lost.
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Pay_My_Claims

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Re: usuall and customary charges
« Reply #8 on: July 03, 2009, 03:31:27 PM »
BCBS will not honor assignment of benefits. A few states have taken them on in court over this and lost.

Yes, and thats why I despise BCBS. They used to be my favorite...LOL. I love them as innet providers :-)
Aint i 2faced  :o

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Re: usuall and customary charges
« Reply #9 on: July 03, 2009, 05:02:20 PM »
Well ..  actually I have never had a problem with it. Any of my clients that don't par I have them collect up front.
In EVERY SINGLE BCBS Policy Handbook and EVERY PROVIDER Contract.. they state this.. so it should never be a surprise, if the doctor is NON par with BCBS..the patient SHOULD be aware and the doctor should be prepared to collect up front. They also have an automated disclaimer when you verify benefits.
Linda Walker
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Pay_My_Claims

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Re: usuall and customary charges
« Reply #10 on: July 03, 2009, 07:59:26 PM »
Well ..  actually I have never had a problem with it. Any of my clients that don't par I have them collect up front.
In EVERY SINGLE BCBS Policy Handbook and EVERY PROVIDER Contract.. they state this.. so it should never be a surprise, if the doctor is NON par with BCBS..the patient SHOULD be aware and the doctor should be prepared to collect up front. They also have an automated disclaimer when you verify benefits.

Unfortunately we deal with clients with ALS, MDA, Paraplegia, Quadriplegia etc. Our rehab chairs run from 20-40K. Most cases our clients have no problem signing the check over to us because they need their equipment. Its just a hassle, because you have to constantly check Blue-e for the payment, since we are not notified that payment has been made. There is a slight difference in paying for an office visit, and rehab equipment. We had a few clients that I had to collect from because they kept the BCBS payment(prior to me coming on doing the AR). If we turn them down, we lose a lot of business, because we are the #1 provider for the ALS & MDA clinic at one of the largest hospitals in NC. I keep on top of the payments!

Michele

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Re: usuall and customary charges
« Reply #11 on: July 03, 2009, 10:06:45 PM »
My docs who are oon (for smaller fee services) usually charge up front and reimburse the patient if and when they receive payment.  For the larger fee services, they tell the patient if they get the money and they bring in the insurance check with the eob, they will give them a courtesy discount.  But if they cash the check and don't sign it over and bring in eob, then they pay full price.  That is incentive for the patient to bring in the money if it goes directly to them.

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PMRNC

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Re: usuall and customary charges
« Reply #12 on: July 04, 2009, 08:51:01 AM »
Your high billing providers should par with BCBS it makes more sense to par than not. Your avg family practices and smaller practices have more practical choices to Not Par. In some cases a large dollar billing provider will be LOSING money NOT participating. On my consulting clients I run reports based on a 2 year period to determine gains and loss with par/non par carriers and almost always the larger practices are losing revenue from being non par with some carriers. There's not many con's for them NOT to par.
Linda Walker
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Pay_My_Claims

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Re: usuall and customary charges
« Reply #13 on: July 04, 2009, 01:13:17 PM »
Your high billing providers should par with BCBS it makes more sense to par than not. Your avg family practices and smaller practices have more practical choices to Not Par. In some cases a large dollar billing provider will be LOSING money NOT participating. On my consulting clients I run reports based on a 2 year period to determine gains and loss with par/non par carriers and almost always the larger practices are losing revenue from being non par with some carriers. There's not many con's for them NOT to par.

We can't because we are DME and they have closed their network to new providers. They are not accepting any more. This holds true for Cigna and UHC. They are not accepting any more DME providers. We have tried to become in net to benefit the clients. They prefer to par with the "scooter store" not realizing that they only market basic wheelchair supplies, and not high end rehab equipment. We do have an advantage of not being par, and being a custom rehab. We get to negotiate a lot of deals because nobody in net can provide the services we can. We are such a different egg, we don't follow the "model"

PMRNC

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Re: usuall and customary charges
« Reply #14 on: July 05, 2009, 12:00:30 AM »
Yeah if the network is closed it's more difficult.. Can you think of anything your practice has that others in same geographic location do NOT have? what about access.. If you can find a "niche" , "service" , or accessibility improvement you can get into a closed network. For example (not DME) I had a client who was a psychologist, we were able to get him into a few "closed" networks because he was doing a procedure called EMDR for PTSD and he was the only one in that geographical location to offer it. Another one of my clients catered to children with Downs Syndrome and Autism so we were able to get him also into some closed panels.
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com