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How to find allowed maximum amount per code of insurance companies

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vchere6535:
Does any one have experience in finding out what the maximum amount billed per CPT code and how to find these criteria from insurance companies? Are we soppose to go by what the doctor tells us he bills? (Does a doc receive a fee schedule when he/she PARed with the insur. co?) If the doctor wants to know how much he can bill to insurance co he does not participate with, what do you tell him? To bill his regular amount and have the inusrance pay what they allow, or will the claim be denied completly this way? thanx

alaughlin:
If you are in-network with the ins. company, you can call and ask for their fee schedule or you can download their schedules on-line. 

Pay_My_Claims:

--- Quote from: vchere6535 on January 09, 2010, 05:49:44 PM ---Does any one have experience in finding out what the maximum amount billed per CPT code and how to find these criteria from insurance companies? Are we soppose to go by what the doctor tells us he bills? (Does a doc receive a fee schedule when he/she PARed with the insur. co?) If the doctor wants to know how much he can bill to insurance co he does not participate with, what do you tell him? To bill his regular amount and have the inusrance pay what they allow, or will the claim be denied completly this way? thanx

--- End quote ---

if you bill less than the allowed you will not receive the full maximum benefit I can tell you that. He should have already had his fee schedule established.

DMK:
It's really important that you get the allowed amounts from several companies and make sure that your U&C is higher than that.  In California, Blue Cross cuts our bills over 50%, Blue Shield pays better, AETNA pays even better.  If your U&C is too low, it can cause the insurance companies to lower the allowed amount the next time their schedule is set.

We got our first raise on Blue Cross in 10 years this year (we get an extra $1 per visit, WOO HOO!).  Blue Shield, however, reduced our allowed amount.

Your doctor's fee schedule should be looked at annually to make sure you're getting all that you can, and to make sure you're billing the right codes!

Sportsmom:
I would go to the Medicare fee schedule and make sure you are higher than Medicare. I just did that for our office and had let the doctor know she lost money last year, because our biller did not know anything about the fee schedule and we did not bill to Medicare max allowed. We now bill 10 % over Medicare.
I all so go the CMAC web site for TRICARE to make sure we are above there fee

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