Fee schedules

[cflorez]

I need some help with fee schedule. For out of network doctors, I am trtying to obtain a fee schedules. Its next to impossible. Does anyone have information on how to obtain or how I can calculate their allowed or pay amounts. As in example for BXBS of GA. The doctor is out of network. I have tryed for weeks to get an answer from them and I keep getting the run around. They act like its top secret. The doctors want to know the allowed amount before they perform the procedures. That fine for Medicare, UHC who have online portals for this information. Does anyone know how to obtain allowed amounts for BXBS of Ga? Thank you

[Michele]

I'm confused as to why they need to know the fee schedule amount if they are out of network?  Usually out of network providers have a fee schedule for their services that is the same no matter what insurance the patient has.  Also, most insurance carriers will not release the fee schedule amounts to out of network providers.

[cflorez]

Most of my clients (Oral Surgeons)  want to know ruffly what they are going to get paid for that procedure. If the medical side will pay less that the dental side then they want the options to bill the dental side.

[Michele]

But if they are out of network don't they collect the entire fee from the patient?  That is usually why providers opt to be out of network, so that they are paid their entire fee by the patient.

[PMRNC]

I have to agree with Michele, you don't need fee schedules if out of network. You go by u&C and you bill patient up to your full charge. If you plan to discount, you should understand that to do so might be fraud unless you have a financial hardship documented.

[ClaimCare]

There is no set and defined payment for out of network providers. Depends on case by case basis and the insurance plans a patient has and what it covers (most of them dont even cover OON benefits) . Not all providers bill to patients btw. They try to get the max from ins and the rest is billed to the patient, provided if any cushion is left.

We gurantee atleast 60% of reimbursements for OON! Thats how we play

[PMRNC]

There is no set and defined payment for out of network providers. Depends on case by case basis and the insurance plans a patient has and what it covers (most of them dont even cover OON benefits) .

What do you mean most don't cover OON benefits?? An HMO maybe but PPO, POS, etc do. OON bases allowables on U&C.
OON providers with high dollar services can send a pre-determination of benefits (CPT Code and provider charge) to the OON carrier to which the carrier will respond that either YES the fee is covered or no it's not.

Not all providers bill to patients btw. They try to get the max from ins and the rest is billed to the patient, provided if any cushion is left.

This is actually fraud unless there is a documented hardship. OON or in network, doesn't matter. Waiving patient out of pocket routinely is fraud.

We gurantee atleast 60% of reimbursements for OON! Thats how we play

Including or not including insurance? That's pretty scary guarantee to make.