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Reimbursement Rates

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mpl:
Hello!

I'm a biller for mental health providers based in WI. This may be a dumb question, but since I only do their billing and I don't work with credentialing, I'm not familiar with how contracts are set up and what information the provider has access to once getting on an insurance panel.

A few of the providers I work with (all practicing as individuals) are considering raising their rates. My first question is whether or not I am able to find out what the maximum reimbursement rates are for the insurance panels that they are on, outside of calling each of the insurance companies and asking. I understand that the provider needs to have the same fee schedule across the board, but they would like to have that information to help determine their new rate.

And my second question is whether there are any steps the provider needs to take before they can raise their rates. For example, do they need to inform the insurance companies that they have contracts with, prior to raising it? And do they need to notify all of their current clients and provide them with an updated fee schedule? Are there any other obvious things that I should be aware of?

Any and all feedback would be greatly appreciated, as this is not at all something I'm familiar with. Thanks so much!

Michele:

--- Quote from: mpl on February 15, 2021, 10:37:25 PM ---A few of the providers I work with (all practicing as individuals) are considering raising their rates. My first question is whether or not I am able to find out what the maximum reimbursement rates are for the insurance panels that they are on, outside of calling each of the insurance companies and asking. I understand that the provider needs to have the same fee schedule across the board, but they would like to have that information to help determine their new rate.

--- End quote ---

Are they billing below the allowed amounts?  The best way is to check the EOBs to see what they are currently allowing.  The only way this doesn't work is if the provider is billing below the allowed amount.  Another method providers use to set a fee schedule is to look up the Medicare allowed amount for their area and multiply that by 130% - 170%.  The most common is 140% - 150%.  Medicare rates are available online, while most insurance carriers do not give out that information with out a phone call.


--- Quote from: mpl on February 15, 2021, 10:37:25 PM ---And my second question is whether there are any steps the provider needs to take before they can raise their rates. For example, do they need to inform the insurance companies that they have contracts with, prior to raising it? And do they need to notify all of their current clients and provide them with an updated fee schedule? Are there any other obvious things that I should be aware of?

--- End quote ---

They do not need to notify the insurance carriers before they change their rates.   ;D

mpl:

--- Quote from: Michele on February 16, 2021, 11:47:42 AM ---
--- Quote from: mpl on February 15, 2021, 10:37:25 PM ---A few of the providers I work with (all practicing as individuals) are considering raising their rates. My first question is whether or not I am able to find out what the maximum reimbursement rates are for the insurance panels that they are on, outside of calling each of the insurance companies and asking. I understand that the provider needs to have the same fee schedule across the board, but they would like to have that information to help determine their new rate.

--- End quote ---

Are they billing below the allowed amounts?  The best way is to check the EOBs to see what they are currently allowing.  The only way this doesn't work is if the provider is billing below the allowed amount.  Another method providers use to set a fee schedule is to look up the Medicare allowed amount for their area and multiply that by 130% - 170%.  The most common is 140% - 150%.  Medicare rates are available online, while most insurance carriers do not give out that information with out a phone call.

--- End quote ---

Yes, they are billing at least $20 below what some of the companies they are paneled with - I'm just not exactly sure how much below. Does it raise a red flag if I do call the insurance company, or is it not recommended that I do that?



--- Quote from: mpl on February 15, 2021, 10:37:25 PM ---And my second question is whether there are any steps the provider needs to take before they can raise their rates. For example, do they need to inform the insurance companies that they have contracts with, prior to raising it? And do they need to notify all of their current clients and provide them with an updated fee schedule? Are there any other obvious things that I should be aware of?

--- End quote ---
They do not need to notify the insurance carriers before they change their rates.   ;D


Great! Is there anything else that they should be aware of when changing rates?
Thanks so much for the response!  :)

Michele:
It doesn't raise any flags but it's a whole lot easier to use the Medicare method.  Most insurance carriers use the Medicare RVUs to calculate their allowed amounts anyway.

I can't think of anything else you need to know.

mpl:
Thank you!   :D

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