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How to find allowed maximum amount per code of insurance companies

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Pay_My_Claims:

--- Quote from: DMK on January 12, 2010, 02:32:22 PM ---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!

--- End quote ---

What specialty are you billing where you get good reimbursment from Aetna?? They are lower than medicaid!!

Michele:
A common rule of thumb is to go between 125 - 130% of the Medicare participating provider allowed amount for your area.

Michele

DMK:
Since I bill chiropractic, I can't really use Medicare as the basis for our fee schedule since they ONLY pay for spinal manipulation.  Aetna pays well for chiropractic, covers modalities and massage therapy, and CostCo employees have Aetna insurance (big employer in our town).  I have found that Blue Shield pays the best for modalities and exams.

PMRNC:
U&C and "Allowable" are NOT the same. An insurance company is NOT allowed to give you U&C. If you are non par without an established fee schedule the procedure is to do a pre-determination of benefits. Your expected CPT code and YOUR fee for that CPT code goes to the carrier. They will either tell you YES the fee is within U&C or tell you the amount it's over.. Your bill when billed had better match that pre-d unless there were other circumstances involved and then it should be documented to reflect the fee difference.  Allowable's are based on the fee schedule with the carrier you par with. These can be disclosed but every carrier has a procedure to which they are disclosed and even how often.

thatcuteblonde:
If you're using Medisoft you can set different fee schedules for different isurance companies, i.e. you can bill Medicare the allowable amount saving you the trouble of taking the adjustment and still bill Worker's Comp their allowable, if they have one. Underbilling will lose the doctor money, but at the same time you don't want to inflate your A/R unnecessarily. If your software doesn't allow you to use multiple fee schedules, use the W/C fee schedule if your state has one. I wouldn't bill less than 125% to 150% of the Medicare fee schedule.

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