Billing > Facility Billing

Fees for Substance abuse and Mental Health

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PMRNC:

--- 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.
--- End quote ---

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.

DMK:
 :)  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:
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:
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:
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.

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