Author Topic: Is there a "STANDARD FEE SCHEDULE RATE 4 PHYSICIAN INSURANCE INSURANCE BILLING?"  (Read 1814 times)

medbillgirl

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I just started billing for a Doctors office and the "owner" of this Medical Office is a business man, not a doctor.  So I deal directly with him. 

This man keeps telling me that they DO NOT have any set price for procedures done in the office except for New Patient $250.00 and Established Patient $180.00. 

HOWEVER, they perform EKG's, PAP SMEAR's, Venipuncture, etc. in the office and they expect me to BILL the Insurance Companies according to some "Physician Standard Fee Schedule Rate."  They claim there is a STANDARD PRICE that they can charge and they are expecting me to figure it out.

I am confused because normally the doctors office give you a "Superbill" with their RATES.  It seems that this office DOES NOT have any established rates except for the NEW PATIENT & ESTABLISHED PATIENT rate. 

Does anyone know if there is a "STANDARD FEE RATE SCHEDULE FOR PHYSICIAN INSURANCE BILLING??"

P.S. This is an established office. The person that use to do their billing (from her home) had to stop because of health issues.

 :( :( :( :( :( :( :(     This is driving me nuts.  Please help!!!!!

Sophrosyne

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Well it seems that you'd bill the patients' insurance company whatever amount you billed the patient. If you bill a patient $250, you bill the insurance $250. If the charge is above the insurance company's allowed amount for a particular procedure, they will discount whatever is above that allowed amount. 
You can bill whatever you want for services. At our office, we bill $150 for individual psychotherapy; however, we've heard of other offices charging $200 for the same service. Each individual insurance company will have its own allowed amount that is (supposedly) based on what other doctors in the area charge for the same procedure. The allowed amount will vary based on the insurance company. For example, Medicare may allow $80 for a service while BCBS may allow $100.
In my opinion, you should just bill the insurance company whatever you bill the patient.


DMK

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This issue has been discussed many times on this forum.  Anyone can charge anything they want, the insurance companies will dictate Usual and Customary and contract rates for your area (this amount will vary greatly from area to area).  The best way to set a fee schedule is to gather EOB's from many different insurance companies you have billed and always charge a bit more than the highest allowed amount.  You must charge every insurance company the same amount for every procedure.  You can have a cash discount when paid at time of service for uninsured patients, and you can have financial hardship accounts that must be CLEARLY spelled out in your policies and procedures. 

Many doctors use the Medicare fee schedule and add 30%.  The "business man" should be making sure that they are covering their costs for providing services.  Many doctors have quit doing certain services because the reimbursement doesn't even cover the cost of providing.

Just out of curiosity, is it legal for a "business man" to own a medical office in your area?  In California a medical or chiropractic practice must be owned by a physician or chiropractor.  There can be a corporation, but one of the officers MUST be a physician or chiropractor.