Author Topic: Fees for Substance abuse and Mental Health  (Read 5960 times)

billingmom

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Fees for Substance abuse and Mental Health
« on: January 09, 2012, 07:01:09 PM »
I still havent been able to find anything out on how much a facility for sub abuse and mental health charge in Florida.  If anyone knows where I can find out please fill me in.    Thanks

PMRNC

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Re: Fees for Substance abuse and Mental Health
« Reply #1 on: January 09, 2012, 07:24:59 PM »
Do you mean the provider's rate's? or are you looking for help in what to charge mental health providers.
Linda Walker
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billingmom

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Re: Fees for Substance abuse and Mental Health
« Reply #2 on: January 09, 2012, 08:47:47 PM »
No not providers.   What they are able to bill insurance companies for fees.  Im thinking there has to be a standard rate out there for inpatient and out patient substance abuse and mental health facilities as well as fees for counseling sessions etc.

billingmom

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Re: Fees for Substance abuse and Mental Health
« Reply #3 on: January 09, 2012, 09:26:51 PM »
What I mean is how much can an inpatient or outpatient facility that provides detox, inpatient treatment or counseling sessions etc. charge as a daily rate.  How do they determine the fee?  Do they just throw out a charge and tell the patients we charge 1,000 per day and we bill your insurance and they only thing your responsible for is dedcutible, co pay, and out of pocket expenses.  I'm seeing that these substance abuse and mental health facilities all charge different rates for the same program.  I came across one that charges $1395.00 per day for residential treatment and then their fees come down a little as the patient is downgraded or stepped down to PHP or IOP services but they still charge alot and bill everything on UB 04.   Im just wondering if there is a price guideline that they have to abide by or do they just set a fee and bill the ins.

DMK

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Re: Fees for Substance abuse and Mental Health
« Reply #4 on: January 10, 2012, 10:28:57 AM »
What's really important for new billers to understand is that facilities and providers can CHARGE anything they like.  The insurance companies set the ALLOWED amount, and all insurance companies have different allowed amounts.  The CHARGED amount  will vary from state to state, area to area, since overhead will vary depending on where your facility is located.  The charged amount helps to set the Usual & Customary fee for each area.  Usual & Customary fees charged are used to determine out of network benefits for some insurance companies.  So there is no specific place to go to find the magic fee for a particular service. 

You may want to call a few insurance companies and find out what they ALLOW for particular programs.  You'll need CPT codes to get allowed amounts.  The fees should always be set higher than the allowed amounts since whatever you charge will be used to determine Usual & Customary fees for your whole area.  So one facility trying to undercut other facilities by having rock bottom prices actually hurts all the other facilities by lowering the U&C average.  That's one of the reasons the whole healthcare system is having trouble.  Doctors and facilities have to be able to make a living in order to stay in business.....and it is a business.

PMRNC

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Re: Fees for Substance abuse and Mental Health
« Reply #5 on: January 10, 2012, 10:37:58 AM »
Quote
The charged amount helps to set the Usual & Customary fee for each area.  Usual & Customary fees charged are used to determine out of network benefits for some insurance companies.  So there is no specific place to go to find the magic fee for a particular service.

Wow, you keep beating me to punch.. do you read my mind now?     YES to the above and the above is why it is so crucial for physicians to NOT bill multiple fee schedules out, while they think it's a good thing and easier on their data entry, it is actually a bad thing on a few different levels. FIRST by billing the lower fee schedules they are mus-reporting data the carriers used to determine U&C and R&C and the other reason is for practice analysis/reporting reasons. By keeping track of the difference between the allowable and the billed charges you can analyze which carriers are a problem, which ones needs thought to possibly negotiate higher reimbursement and you can't get a clear and accurate picture of the health of the practice if your not showing adjustments.     There is a limit set but it means you cannot bill more than 150% of the Medicare allowable..that is the standard guideline.  I would also stress NOT to get into this portion of the business unless you have quite a few years of experience under your belt. Provider's can hire consultant's for exactly this reason and also to help with fee schedule and contract negotiations.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

DMK

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Re: Fees for Substance abuse and Mental Health
« Reply #6 on: January 10, 2012, 11:09:10 AM »
 :)  Linda I'm so proud of myself when I'm on your same track.  I still don't know the legalities of everything, but I have a layman's understanding of the business aspect.

billinggirl

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Re: Fees for Substance abuse and Mental Health
« Reply #7 on: January 10, 2012, 12:03:27 PM »
Thank you so so much.  Thats what I thought but I needed someone to confirm it to me.  So part of the reason they raise the prices so high is to get a reimbursement at a higher rate?  CUz I noticed that some of the facilities are inflated and some are just dirt cheap.  No its making sense.   

DMK

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Re: Fees for Substance abuse and Mental Health
« Reply #8 on: January 11, 2012, 10:17:33 AM »
They won't get a higher reimbursement for charging a higher rate (they are basically keeping the "going rate" high enough to stay in business).  The insurance companies still have an ALLOWED amount for participating providers.  If the provider is NON-Par, there is still Usual & Customary.  The insurance companies set the "going rate".  Unfortunately, the only person that ends up paying more is the cash patient or non-par patients.  That's why the facility/provider needs to have a CLEAR financial policy with regards to financial hardship, cash discounts, etc.  And EVERYONE needs to be treated the same.

DMK

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Re: Fees for Substance abuse and Mental Health
« Reply #9 on: January 11, 2012, 11:07:06 AM »
Yes.  I guess a better way to put it is that if everyone charges $5 for a loaf of bread, and the insurance company gets participating providers to agree to take $4 for a loaf of bread, then the "going rate" is $4.  If they're losing money at $4, they won't be in business in a very short period of time.  That's when you negotiate with the insurance companies (Linda would have to explain that, I didn't know that was an option.), and/or raise your charges.

Don't sell your business short.  If there's not a cross on the door, it's not a charity.  The business gets to make a profit. 

I'm probably not going to make any friends when I say this, but even healthcare is a business.  When offices run on no money, care starts to suffer.  It shouldn't be a free for all by any means, but there should be enough profit for things to run cleanly and efficiently.  That's why so many doctors are bailing out of providing for Medicare patients.  Their reimbursement has been cut steeply and overhead costs continue to rise.  And this segment of the population NEEDS a lot of care, their cases are complex and complicated.  And now I'm going to get off my soapbox......Sorry.


billinggirl

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Re: Fees for Substance abuse and Mental Health
« Reply #10 on: January 11, 2012, 11:50:56 AM »
Very well said, and i agree and understand the issues with medicare.  Doctors are getting reimbursed pennies for services that cost them alot more.

PMRNC

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Re: Fees for Substance abuse and Mental Health
« Reply #11 on: January 11, 2012, 02:31:06 PM »
Quote
I'm probably not going to make any friends when I say this, but even healthcare is a business.  When offices run on no money, care starts to suffer.  It shouldn't be a free for all by any means, but there should be enough profit for things to run cleanly and efficiently.  That's why so many doctors are bailing out of providing for Medicare patients.  Their reimbursement has been cut steeply and overhead costs continue to rise.  And this segment of the population NEEDS a lot of care, their cases are complex and complicated.  And now I'm going to get off my soapbox......Sorry.

You won't get a difference in opinion from me.. this is VERY true, unfortunately there are so many people who still believe that doctors are getting rich and riding around in Mercedes Benz..That's an OLD myth!  I cannot believe how many provider's make this look like it's true, when I go in to an office the first things I want to see is their financial policy and their office policy, the ones patients see and sign.. I can't believe how many do not have one.  In fact many time billers will come to this forum or other forum's and ask.. we have this patient with a $500 deductible can we just collect $100 and the answer is supposed to be with the office financial policy .. and it should be clear and concise and above all carry through for ALL patients. When there is one, those kind of questions need not come up. I have one provider who's financial hardship agreement is 3 pages long and he makes patients SHOW hardship, if they have full cable packages with HBO and Showtime and internet connection, they can pay their deductibles.  Some patient's resent that but he simply tells them he's able to keep things fair among all patients.   They are in business too and they are in one of the most heavily regulated businesses there are so they have to make money in order to stay in business.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com