Author Topic: Usual & Customary Fee Schedule  (Read 4945 times)

dfranklin

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Usual & Customary Fee Schedule
« on: August 06, 2009, 11:49:08 AM »
I have a provider that paid to get a report for his area of Usual & Customary Fees.  He faxed this to me and it has columns to the right for P50, P75, P90...I assume these are percentages...it also has columns for RVU and RVU$.  Does anyone know how to read this and what those columns mean? 

Under what i thnk are the percentages there are different fee prices. Doe anyone know what one the provider should be going by?

My provider wants to update his pricing to be charging the U&C for his area but he does not know what to follow on this report and was asking me as his biller...I would like to be able to give him an educational answer other then go back to the person that gave you the report. He is a new client of mine so I would like to go above and beyond and find this out for him.  If nobody can answer can anyone point me in the direction to find the answers?

Thanks!

Don

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Re: Usual & Customary Fee Schedule
« Reply #1 on: August 06, 2009, 12:19:48 PM »
I know of no such lists. Certainly doctors obtain copies of their fee schedules, but U&C is a formula used by carriers to determine Usual & Customary, they use various sources such as the HIAA and of course data they obtain from providers (this is why it's important providers bill THEIR charges, not fee schedule amounts or U&C)

There are actually laws regarding gathering "lists" of provider fees.. so I'd be cautious but I don't know where you obtained such a list so I can't really say more about that. The P50, P75 and P90 stand for the Percentile of the HIAA (75th Percentile, 90th Percentile...etc)
Doctors again are not privy to U&C is for data collection by carriers. 

Quote
My provider wants to update his pricing to be charging the U&C for his area but

Why?
this makes no sense why doctors would do this as they then cut off their noses to spite their faces. Again, U&C is determined and based on a lot of variables, one of them being what doctors report as their charges. When physicians begin to take their fees down to U&C or even Fee schedule allowable they distort the data collection thus in turn begins the breakdown of the U&C and ultimately hurts providers. 
Linda Walker
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dfranklin

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Re: Usual & Customary Fee Schedule
« Reply #2 on: August 06, 2009, 01:01:04 PM »

On top of the report it says:
Physician's Fee Reference 2009
PFR Fee Information 2009 Wasserman Medical Publishers LTD
CPT 2008 American Medical Association
Licensed to: (Gives a name I am assuming of the person that ran the report for the provider)
For Zip Code: ANd it gives my provider's zip

And then lists all of the codes with the prices under the columns I mentioned.....

I think what it is is a fee schedule showing what other doctors in the same geographic area are charging for the same procedures....I think the provider wants to analyze his fees and bill according to competition...be competitive yet not overbill or underbill...I did a google search and found many resources where you can do this for like $299 and up...either software that will analyze your charges, or give you the charges for the area or books etc...

I am trying to find out if he should go with the P90 or what to tell him on this...or should I tell these columns are what is Usual & Customary for other providers in your area...but you should charge what you feel is appropriate even if it is more..becuase if you drop down just to be within "Usual & Customary" then you are lowering this and that is what carriers go off of...and if other providers drop too then it will really hurt you (providers) in the long run...does that make sense or is there a different way I should explain this to the provider?

Thanks!

Pay_My_Claims

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Re: Usual & Customary Fee Schedule
« Reply #3 on: August 06, 2009, 01:05:31 PM »
 ???

PMRNC

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Re: Usual & Customary Fee Schedule
« Reply #4 on: August 06, 2009, 01:32:18 PM »
Your top 5 carriers use 90th Percentile.  This book you mentioned is a GUIDE, merely based on statistics.
But it should serve your purpose, though I don't know if you should get into this with the provider, I think it's best to have them get someone with more experience and also work with their attorney to be sure there is no price fixing taking place. Certain things are really out of the scope of our practice.
Linda Walker
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Steve Verno CMBS, CEMCS

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Re: Usual & Customary Fee Schedule
« Reply #5 on: August 08, 2009, 08:10:38 AM »
The guide I am thinking about may have been created by Inginex.  Inginex is owned by United Healthcare.  It has also been the subject in recent court cases and State investigations.  One insurance company told us they pay at the 95% of Inginex's data. 

Our charge for a service was $125 but the insurance company said our fee, per Inginex was too high.  My comment to this is.  we are the only specialty in the geographical area where the care is provided.  For example, you are in the desert.  No other gas stations are around fo 200 miles.  The price of gas is $3.00 per gallon. The Inginex data might say that the gas should be $1.50 per gallon based on usual and customary for the geographical area.  This makes no sense.  If you are the only gas station and you charge $4.00 then the usual and customary is $4.00.  Its as simple as that. 

Here, Usual and Customary is a HUGE issue. State law mentions UCR but it states the Providers usual and customary charges.  The HMOs have gone so far as to argue that the UCR is 125% of the Medicare allowable. One lawyer representing the HMOs stated that a providers charges is what the HMO reimburses a provider.  To me, a providers charge is the fee he/she represents and bills for servics rendered, but I am not a lawyer, so what do I know.  One insurance company recently decided to settle all claims paid at their UCR (125% of Medicare), at 239% of Medicare.  Sounds nice, but, not really

Now, the insurance company is demanding refunds for all claims paid at more than 239% of Medicare and they are now setting 239% as the usual and customary fee for non-par poviders in my state. 



 
I'l have a double chubby chuck, a mexicali chilibarb, and two cherry cokes
Left hand Blue, Right Leg Green
You got your peanut butter on my milk chocolate.
Dont cut the blue wire! 
I love spam.

Pay_My_Claims

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Re: Usual & Customary Fee Schedule
« Reply #6 on: August 08, 2009, 05:30:39 PM »
The guide I am thinking about may have been created by Inginex.  Inginex is owned by United Healthcare.  It has also been the subject in recent court cases and State investigations.  One insurance company told us they pay at the 95% of Inginex's data. 

Our charge for a service was $125 but the insurance company said our fee, per Inginex was too high.  My comment to this is.  we are the only specialty in the geographical area where the care is provided.  For example, you are in the desert.  No other gas stations are around fo 200 miles.  The price of gas is $3.00 per gallon. The Inginex data might say that the gas should be $1.50 per gallon based on usual and customary for the geographical area.  This makes no sense.  If you are the only gas station and you charge $4.00 then the usual and customary is $4.00.  Its as simple as that. 

Here, Usual and Customary is a HUGE issue. State law mentions UCR but it states the Providers usual and customary charges.  The HMOs have gone so far as to argue that the UCR is 125% of the Medicare allowable. One lawyer representing the HMOs stated that a providers charges is what the HMO reimburses a provider.  To me, a providers charge is the fee he/she represents and bills for servics rendered, but I am not a lawyer, so what do I know.  One insurance company recently decided to settle all claims paid at their UCR (125% of Medicare), at 239% of Medicare.  Sounds nice, but, not really

Now, the insurance company is demanding refunds for all claims paid at more than 239% of Medicare and they are now setting 239% as the usual and customary fee for non-par poviders in my state. 



 

Hummmmmmmm I kept thinking I know this poster, and I believe I do. Your writting is Unique!!

Steve Verno CMBS, CEMCS

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Re: Usual & Customary Fee Schedule
« Reply #7 on: August 08, 2009, 08:07:24 PM »
Ollie Ollie Oxen Free

Peek a Boo! ;D
I'l have a double chubby chuck, a mexicali chilibarb, and two cherry cokes
Left hand Blue, Right Leg Green
You got your peanut butter on my milk chocolate.
Dont cut the blue wire! 
I love spam.

PMRNC

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Re: Usual & Customary Fee Schedule
« Reply #8 on: August 08, 2009, 08:54:19 PM »
Stalker!!! :-\
Linda Walker
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Pay_My_Claims

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Re: Usual & Customary Fee Schedule
« Reply #9 on: August 09, 2009, 08:53:12 AM »
Yes, I'm afraid now Linda......