Filling out the charges part on the claim form

[lauracollins]

Hi,

I've just started my own practice and I am new to filing claims.  I want to file a claim for a patient who has coverage through Optum (I'm in-network) for their behavioral health.  On the online claim form where it asks you to enter charges, do I put my charges for that particular service or do I put what the fee reimbursement is for my contract with Optum for that service?  Thanks,

Laura

[Michele]

Technically you can put either.  We recommend that you put your regular fee schedule amount and then right off the contractual adjustment once payment is made.

[lauracollins]

Thanks Michele!  Do you happen to know what the rules are surrounding dual fee schedules? Is it true that your regular fee schedule has to be the same for all insurances?  Can you have a separate fee schedule for self-pay patients?  Thanks, Laura

[Michele]

You are supposed to charge the same to all patients, regardless of insurance or lack of.  Otherwise it may be considered insurance fraud, or it may break contracts that you have with insurance carriers.  The safest route is to charge the same for all patients.  However, there are some things you can do if you are looking to have a lower rate for patients without insurance.

[lauracollins]

Thanks so much for clarifying!  Super helpful - I just wanted to make sure I understood after reading up on all this.  What are some ways around possibly charging less if the patient doesn't have much money?  If they have medicaid, but I'm not yet a medicaid provider, do you know if medicaid would still reimburse me or would I have to charge them the my usual fee for that service?

[Michele]

I'm not sure what state you are in but most states do not allow a provider to bill/charge a Medicaid patient.  So with Medicaid you have to wait until you are a Medicaid provider.

As for charging less, you can set up a sliding fee schedule so that patients who don't have insurance can pay based on their income. 

[lauracollins]

Thanks again so much.  My contact person from Cigna told me that I can charge self pay patients whatever I want and that it doesn't have to be the same as what charge I put on my insurance claims...  Oy...  Is this one of those areas where people don't know all the rules you think?

[PMRNC]

As Michele stated, it's best to have ONE fee schedule for all patients. With cash patients you can do a discount but for the patient's statement/encounter it should show.

It's extremely important that you have a clear patient financial policy in place as that is what you follow for all of the questions asked.
Many providers think it's easy to do their own billing but I assure you it's not and could cost more than you imagine. Recommend you get all policies and procedures in place (they are mandatory anyway) along with full patient financial policy that clearly outlines the procedure to all patients.

[lauracollins]

Thanks Linda, I feel a lot better now after getting you and Michele's feedback!  Really appreciate it!