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 set application rules. All forms need to be filled out without any errors, all required attachments have to be current, and follow-ups need to be done regularly. 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-ups and get providers in-network quickly. We can also help create self-pay fee schedules by comparing data from insurances and local providers. Contact us for details. 

Importance of Fee Schedule Analysis

We always ask practices to maintain individual files for contracted insurances. In case you are missing any fee schedule information, we can help you recover them. Fee schedules are important to determine reimbursement for services, verifying accurate payments on EOBs, pre-collection for deductible and co-insurance, separating bundled services, listing services on the claim form, and renegotiating fees when applicable. Insurances publish new schedules 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 provider is being paid correctly.


Fee Schedule Analysis


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.

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