Author Topic: Provider Charges  (Read 1139 times)

mbloom

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Provider Charges
« on: May 07, 2013, 08:45:38 AM »
Can providers charge more that the insurance allowable and if so- can they actually collect on that balance (which would be more than what the insurance shows do?)


Also, for private carriers like BCBS, do they follow closely with the Medicare allowables?


PMRNC

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Re: Provider Charges
« Reply #1 on: May 07, 2013, 08:56:31 AM »
Quote
Can providers charge more that the insurance allowable and if so- can they actually collect on that balance (which would be more than what the insurance shows do?)

The physician can charge more but it's important to note the difference between allowable in regards to a fee schedule allowable and Usual and Customary allowable. Fee-schedule is the amount the carrier allows with a participating contract / agreement between the carrier/plan and the provider. Still a physician can charge more but they will not be reimbursed over the allowable (and minding any out of pocket copay, coinsurance, deductibles).  With U&C this is the allowed amount the carrier deems as usual & customary using their own formula based on a 90th percentile (HIAA) there is no network agreement (non par) when a carrier deems a charge above R&C/U&C. Yes there can be appeals filed for more or full consideration of full amount but every situation is different, you may need notes, operative report, etc or any other supporting documentation used to justify the higher cost above the carriers U&C amount.

Best way to avoid surprises with large dollar claims and U&C (Again, NON PAR PLANS) is to submit a pre-determination to the carrier with the procedure and the fee to be charged. The carrier will tell you YES or NO the charge is within reasonable and customary. They will NOT give you the R&C amount as that would create an unfair advantage and incentive to fraud if the amount were to be higher than the physicians charge.  Call the carrier and find out what their procedure is for submitting a pre-determination. Some will let you fax it.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
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