Fee Schedule Analysis

Doctors need to have copies of all insurance contracts on file. When a contract is completed between provider/practice and insurance, contracted fee schedule will indicate maximum allowable for covered services. Doctors also need to review their contracts and fee schedules each year to determine if request needs to be submitted for fee increase.

Insurance contracting is a tedious and time-consuming process, but a necessary one. In order to be in-network with insurances, providers have to follow application rules. All forms need to be filled out without any errors, all required attachments have to be current, and follow-up needs to be done on regular intervals. If providers see patients before the contracted start date, claims will not get paid.

We work with all insurances in all states. Insurances will have different reimbursement rates assigned to each CPT code. For self-pay patients, clinics will need to create an in-house fee schedule. These charges need to be decided by the practice. With new law passed in January of 2022, self-pay patients need to be given a good faith estimate before treatment.

Providers can depend on us to get insurance contracting done efficiently. We will submit all applications and do all follow-up and get providers in-network quickly. We can also help create self-pay fee schedules by comparing data from insurances and local providers.

Fee Schedule Analysis

Importance of Reimbursement Analysis

We always ask practices to maintain files for contracted insurances. In case you are missing any contract or fee schedule information, we can help you recover them. Fee schedules are important for determining reimbursement for services, verifying accurate payments on EOBs, calculating deductible and co-insurance, identifying bundled services, listing services on the claim form, and negotiating fees when applicable. Some insurances publish new reimbursement schedule yearly, so billers need to update their records accordingly. Do keep in mind that insurances have many different plans under one umbrella. Fee schedules must be obtained for each plan. Proper payment posting cannot be done without fee schedules. While posting payments from EOBs, our billers cross-checks with fee schedule to ensure claim is being paid correctly.

Fees Schedule Nuances

Physician Fee Schedule

Insurance fee schedules can be categorized into three main groups, Medicare, Medicaid, and Commercial. Medicare is serviced by Medicare Administrative Contractors (MACs), these are private, independent contractors. Each contractor will have its own fee schedule for each geographical location. If a provider treats patients in more than one location, there might be different MACs with different fee schedules for each location.

Medicaid claims are processed by individual state with their set fees. If a provider treats out of state Medicaid patient who does not fall under provider specific state contracted fee schedule, claim will not be paid.

Each commercial insurance has it’s own physician fee schedule. Review them carefully each year because they might not update fees for provider unless a formal request is made. If provider’s current fee schedule is low, a strong attempt should be made to renegotiate fees.

Physician Fee Schedule
Self-Pay Patient Fee Schedule

Self-Pay Fee Schedule

Many patients are not covered by insurance, for these patients, clinic’s self-pay or cash-pay fee schedules will apply. Per No Surprise Act of 2022, self-pay patients will have to be given a Good Faith Estimate of fees for services. Clinics can set their fees as they wish, but it has to be a reasonable cost per service area and services types. Self-Pay rate cannot be less than what the provider charges Medicare patients.

FAQ

Fee schedules indicate the maximum reimbursement for services.

Individual insurances determine its own fee schedule and fees for some services may change from year to year.

Allowable fee is the contracted rate insurance will pay provider for services.

Fee schedules are determined by insurances at the time of contracting with providers. Once the contract is signed by both parties, the Fee Schedule becomes the negotiated reimbursement rate. Fee schedules might increase or decrease yearly as allowed by the contract.

Fee Schedule indicates reimbursement for services.

Fee Schedule is the contracted fee between insurance and provider which indicates the agreed reimbursement amount for each service the provider renders.

This is definitely a red flag issue to avoid. Dual fee schedule is when medical practice charges less to self-pay or cash-pay patients then it does to insurances.