Fee Schedule too high?

[AKA]

Hi everyone!
I will be working with a physical therapy provider and the provider is out of network with insurance companies. This provider wants to bill 400% of the Medicare fee schedule and I know out-of-network providers can set their own fee schedule. And I've also worked with other providers who have billed up to 200% of the Medicare fee schedule. But does 400% seem too high? Is there such a thing as billing insurance companies too high? Provider is based in NJ if that matters.

[Michele]

I've been in this business for over 25 years.  To me 400% is high.  Do they plan on collecting the entire 400% from the patient for each visit?

I have seen providers who do have very high fee schedules, but it is definitely not common.  We have one specialist in NYC who charges about 400% but out of all of our providers that is the only one that high. 

My personal opinion is that with PT, patients are usually seen 2 - 3 x's per week.  With a 400% above MCR fee schedule that will make it difficult for patients and I think it would greatly hurt their business.  I would not go to an out of network PT, especially if they are charging me that much.  JMO

[PMRNC]

Agree 400 times is way too high. 100-300 is more of the average. Your adjustments will be way too high.

[kristin]

Agree with Michele and Linda, 400% is WAY too high. Why would the provider want to "sticker shock" patients with prices like that? I too would not choose to see this provider, even if they were in network with my insurance, because I can't tolerate business practices like that. While I am all about fair reimbursement for providers, there is a difference between fair, and outrageous.

My personal approach to setting a fee schedule (none of my providers do WC claims) is to every year get Medicare's fee schedule, and the fee schedule of my highest payer (BCBS) and whichever of them has the highest allowed amount for a code, I take that number, and round up to the nearest whole dollar amount. So $78.23 for a 99213 is set at $80.00. That keeps the adjustments down, the AR in line, and the patients from freaking out when they see their EOB's.