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The Importance of Having an Accurate Fee Schedule


Your fee schedule is the heart of your medical practice. Now is the time to get your allowable rates updated and published to your staff and billing department.

Each January, you are so busy reviewing last year's business data, that you might consider the review of your fee schedule less important. But now is the time to get your grid updated now that Medicare has released their new rates.

Why is getting your fee schedule updated so critical? Here are a few scenarios where things can go very wrong, very quickly without the correct rates:

Probably the most important reason is so that you can input your updated rates into your billing software. Some of the newer programs are becoming more and more finessed with the ability to raise red flag when posted payments do not match your allowable amounts. You could be losing so much in Inflow by just not knowing if you are being paid your contracted rates. Insurance companies are notorious for under paying. If your billing department does not know that you are being paid incorrectly, they have no recourse in following up.

Your front office staff collecting co-insurance and deductibles must have updated rates. Of course patients are told “this is an estimation; it could be more or less." Once the insurance company processes, the patient may be due a refund, or be sent a bill. If you end up having to send a bill due to your rates being incorrect, the likelihood of being paid the difference is rather slim. People feel that once they pay up front, that should be it and the mistake was yours. This gets difficult since it is considered insurance fraud to adjust off a patient's deductible.

Having an individual either in your billing department or administrative department reviewing all of your contracts on an annual basis is a very important task that must be completed. So many insurance companies have gravitated towards cascading, resulting in tremendous loss for your practice. Do you know which ones now cascade their allowable amounts? For example: If you use a particular 15-minute timed procedure code for an hour, the results are shocking once you start cascading. If you are paid $46.15 for CPT code 99999, and see the patient for an hour, your allowable amount would equate to $184.60. Taking this same code, and now the insurance cascades and pays 100 percent for the first code, 80 percent for the second, and 40 percent for the third and fourth codes, your allowable amount now equates to $119.99. This is a difference of $64.61 for the single visit. This is your pay cut from the insurance company without actually reducing your contracted rate; sneaky of them. Find out which ones cascade their rates, and be sure you are coding correctly for those particular insurances.

With just a few hours of invested time, you can avoid problems in three major areas of your practice. Arming yourself with up-to-date information is the first step in insuring you are paid what you deserve. With all of the changes that are being imposed upon you with the Affordable Care Act, you owe it to yourself to invest the time up front that will protect your business.

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